Gerontological Nursing, 10e - Charlotte Eliopoulos

Gerontological Nursing
TENTH EDITION
TENTH EDITION
Charlotte Eliopoulos, PhD, MPH, RN
Specialist in Holistic Gerontological Care
Vice President, Nursing Segment: Julie K. Stegman
Manager, Nursing Education and Practice Content: Jamie Blum
Acquisitions Editor: Michael Kerns
Senior Development Editor: Meredith L. Brittain
Editorial Coordinator: Vinoth Ezhumalai
Marketing Manager: Brittany Clements
Editorial Assistant: Molly Kennedy
Production Project Manager: Sadie Buckallew
Design Coordinator: Steve Druding
Art Director: Jennifer Clements
Manufacturing Coordinator: Karin Duffield
Prepress Vendor: SPi Global
Tenth Edition
Copyright © 2022 Wolters Kluwer
All rights reserved. This book is protected by copyright. No part of this book may be reproduced or
transmitted in any form or by any means, including as photocopies or scanned-in or other electronic
copies, or utilized by any information storage and retrieval system without written permission from
the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials
appearing in this book prepared by individuals as part of their official duties as U.S. government
employees are not covered by the above-mentioned copyright. To request permission, Wolters
Kluwer at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at
permissions@lww.com, or via our website at shop.lww.com (products and services).
987654321
Printed in China
Cataloging-in-Publication Data available on request from the Publisher

ISBN: 978-1-9751-6100-2
This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied,
including any warranties as to accuracy, comprehensiveness, or currency of the content of this work.
This work is no substitute for individual patient assessment based upon healthcare professionals’
examination of each patient and consideration of, among other things, age, weight, gender, current or
prior medical conditions, medication history, laboratory data and other factors unique to the patient.
The publisher does not provide medical advice or guidance and this work is merely a reference tool.
Healthcare professionals, and not the publisher, are solely responsible for the use of this work
including all medical judgments and for any resulting diagnosis and treatments.
Given continuous, rapid advances in medical science and health information, independent
professional verification of medical diagnoses, indications, appropriate pharmaceutical selections and
dosages, and treatment options should be made, and healthcare professionals should consult a variety
of sources. When prescribing medication, healthcare professionals are advised to consult the product
information sheet (the manufacturer’s package insert) accompanying each drug to verify, among
other things, conditions of use, warnings and side effects and identify any changes in dosage
schedule or contraindications, particularly if the medication to be administered is new, infrequently
used or has a narrow therapeutic range. To the maximum extent permitted under applicable law, no
responsibility is assumed by the publisher for any injury and/or damage to persons or property, as a
matter of products liability, negligence law or otherwise, or from any reference to or use by any
person of this work.
shop.lww.com
This book is dedicated to my husband, George Considine, for his
unending patience, support, and encouragement.
Contributors
Moreen Areh, RN, BSN, MSN, FNP, DNP

CEO/President of L & G
Medical Consulting Firm
Marietta, Georgia
Next Generation NCLEX-Style Cases and Questions
Sherry A. Greenberg, PhD, RN, GNP-BC, FGSA, FAANP,

FAAN
Associate Professor
Seton Hall University College of Nursing
Interprofessional Health Sciences Campus
Nutley, New Jersey
Chapter 21, Mobility
Chapter 27, Mental Health Disorders
Chapter 28, Delirium and Dementia
Margaret Huryk, DNP, APN-C

Assistant Professor
Seton Hall University
Adult and Geriatric Primary Care Nurse Practitioner
Raritan Bay Cardiology Group at Roosevelt Care Center
Edison, New Jersey
Chapter 24, Endocrine Function
Linda Turchin, MSN, RN, CNE

Professor Emeritus
School of Nursing
Fairmont State University
Fairmont, West Virginia
Next Generation NCLEX-Style Cases and Questions
Reviewers
Mary Beaudry, DNP, MSNed, MA, RN

Assistant Professor
Ferris State University
Big Rapids, Michigan
Meg Bourbonniere, PhD, RN

Assistant Professor (Retired)
University of Rhode Island
Kingston, Rhode Island
Sarah Gilbert, PhD, RN, GCNS-BC

Associate Professor
Radford University
Radford, Virginia
Elsie A. Jolade, DNP, FNP-BC, ACNS, EdM, APRN, CCRN

Clinical Professor
Hunter College City University of New York
New York, New York
Joy D. Kimbrell, DNP, RN, CNE

Associate Professor and Program Director
Cumberland University
Lebanon, Tennessee
Miranda Knapp, DNP, APRN, AGCNS-BC

Assistant Professor
Mount Carmel College of Nursing
Columbus, Ohio
Debra Parker, DNP, RN

Assistant Professor
Indiana Wesleyan University
Marion, Indiana
Ashley J. Polzer, MSN, RN

Lecturer
University of Wisconsin Oshkosh
Oshkosh, Wisconsin
Leah Richardson, PhD, MSN, RN

Clinical Assistant Professor
University of Arkansas for Medical Sciences
Little Rock, Arkansas
Preface
Not only are nurses in virtually every health care setting engaged in some
form of gerontological nursing, they also are facing new challenges as they
work with the growing number of older individuals. Increasing diversity is
found in this population in regard to health status, ethnicity, race, religion,
family profile, sexual orientation, lifestyle, health goals, and other factors.
As compared to previous generations, today’s older adults are better
informed about their health care, expect to have treatment options
thoroughly discussed with them, and want to actively participate in the plan
of care developed. In addition to the management of the many chronic
conditions that increase in prevalence with age, today’s older adults may
seek advice and assistance for measures to sharpen mental function, avoid
vaginal discomfort during intercourse, cope with the behavioral problems of
the grandchildren they are raising, reduce facial wrinkles, select the best
nursing home to meet their needs, manage the anxiety experienced as they
confront retirement, deal with grief over the death of their lesbian partner,
or properly use medical marijuana for pain relief. They are interested in
exploring complementary and alternative therapies that can assist them with
maintaining their health and managing health conditions. The diversity,
needs, interests, and expectations of today’s older population definitely
cause gerontological nursing to be a highly complex and interesting
specialty.
Like the older population, Gerontological Nursing has changed over the
years. The first edition of this text was launched when the specialty of
gerontological nursing was young. At that time, the challenge was for
nurses to gain an understanding of the normal aging process and the unique
aspects of caring for the diseases older adults presented. Today, the
complexities of gerontological nursing require nurses to possess a wider
range of information. This 10th edition of Gerontological Nursing provides
evidence-based knowledge on a wide range of topics to equip nurses to
meet—comprehensively and effectively—the holistic needs of a diverse
older population.
TEXT ORGANIZATION
Gerontological Nursing, 10th edition, is organized into five units. Unit 1,
The Aging Experience, provides basic knowledge about the older
population and the aging process. The growing cultural and sexual diversity
of this population is discussed, along with the navigation of life transitions
and the changes to the body and mind that typically are experienced.
Unit 2, Foundations of Gerontological Nursing, provides an
understanding of the development and scope of the specialty, along with
descriptions of the various settings that provide services to older persons.
This unit reviews legal and ethical issues that are relevant to gerontological
nursing and offers guidance in applying a holistic model to gerontological
care.
Unit 3, Health Promotion, addresses the importance of measures to
prevent illness and maximize function. Chapters dedicated to nutrition and
hydration, sleep and rest, comfort and pain management, safety, and
medications guide the nurse in identifying unique factors that can create
risks, promoting basic health, and preventing avoidable complications.
Unit 4, Geriatric Care, encompasses chapters dedicated to respiration,
circulation, digestion and bowel elimination, urinary elimination,
reproductive system health, mobility, neurologic function, vision and
hearing, endocrine function, skin health, and cancer. A review of the impact
of aging, interventions to promote health, the unique presentation and
treatment of illnesses, and integrative approaches to illness are discussed
within each of these areas. In addition to a chapter on mental health
disorders, a chapter reviewing delirium and dementia is included in
recognition of the prevalence and care challenges of these conditions in the
geriatric population. Because chronic conditions affect most of this
population, the last chapter of this unit is dedicated to nursing actions that
can assist older individuals in living a full life with chronic conditions.
The unique challenges gerontological nurses face in various care
settings are discussed in Unit 5, Settings and Special Issues in Geriatric
Care. Chapters in this unit cover rehabilitative care, acute care, long-term
care, family caregiving, and end-of-life care. Chapters dedicated to
spirituality and sexuality/intimacy support the holistic approach that is
meaningful in gerontological care.
FEATURES
A variety of features enrich the content:
NEW! Next Generation NCLEX-Style Case Studies and Questions

related to chapters on clinical topics (Unit 3 [Chapters 11 through 15]
and Unit 4 [Chapters 16 through 29]) help students review important
concepts and practice for the Next Generation NCLEX. The cases are
found in the chapters, and the related questions and answers are found
in online Appendices A and B. For your convenience, a list of these
case studies found in the chapters, along with their location in the
book, appears in the “Index of Selected Features” section later in this
front matter.
NEW! Unfolding Patient Stories, written by the National League for
Nursing, are an engaging way to begin meaningful conversations in the
classroom. These vignettes, which appear throughout the text near
related content, feature patients from Wolters Kluwer’s vSim for
Nursing | Gerontology (codeveloped by Laerdal Medical) and
DocuCare products; however, each Unfolding Patient Story in the
book stands alone, not requiring purchase of these products. For your
convenience, a list of these case studies, along with their location in
the book, appears in the “Index of Selected Features” section later in
this front matter.
Chapter Outlines present an overview of the chapter’s content.
Learning Objectives prepare the reader for outcomes anticipated in
reading the chapter.
Terms to Know define new terms pertaining to the topic.
Communication Tips offer suggestions to facilitate patient education
and information exchange with older adults.
Consider This Case features present clinical situations that offer
opportunities for critical thinking. For your convenience, a list of these
case studies, along with their location in the book, appears in the
“Index of Selected Features” section later in this front matter.
Concept Mastery Alerts clarify fundamental nursing concepts to
improve the reader’s understanding of potentially confusing topics, as
identified by Misconception Alerts in Lippincott’s Adaptive Learning
Powered by PrepU.
Key Concepts emphasize significant facts.
Points to Ponder pose questions to stimulate thinking related to the
content.
Assessment Guides outline the components of general observations,
interview, and physical assessment of major body systems. For your
convenience, a list of the assessment guides, along with their location
in the book, appears in the “Index of Selected Features” section later in
this front matter.
Nursing Problem Highlights provide an overview of selected nursing
problems common in older adults.
Nursing Care Plans demonstrate the steps in developing nursing
problems, goals, and actions from identified needs. For your
convenience, a list of the nursing care plans, along with their location
in the book, appears in the “Index of Selected Features” section later in
this front matter.
Bringing Research to Life presents current research and describes
how to apply that knowledge in practice.
Practice Realities pose real-life examples of challenges that could be
faced by a nurse in practice.
Critical Thinking Exercises guide application.
Chapter Summary reinforces key points and concepts.
Resources and References assist with additional exploration of the
topic.
A COMPREHENSIVE PACKAGE
FOR TEACHING AND
LEARNING
To further facilitate teaching and learning, a carefully designed ancillary
package has been developed to assist faculty and students.
Resources for Instructors

Tools to assist you with teaching your course are available upon adoption of
this text at http://thePoint.lww.com/Eliopoulos10e.
An E-book on gives you access to the book’s full text and images
online.
The Test Generator lets you put together exclusive new tests from a
bank containing hundreds of questions to help you in assessing your
students’ understanding of the material. Test questions link to chapter
learning objectives. This test generator comes with a bank of more
than 900 questions.
PowerPoint Presentations provide an easy way for you to integrate
the textbook with your students’ classroom experience, via either slide
shows or handouts. Multiple choice and true/false questions are
integrated into the presentations to promote class participation and
allow you to use i-clicker technology.
Clinical Scenarios posing What If questions (and suggested answers)
give your students an opportunity to apply their knowledge to a client
case similar to ones they might encounter in practice.
Assignments (and suggested answers) include group, written, clinical,
and web assignments.
An Image Bank lets you use the photographs and illustrations from
this textbook in your PowerPoint slides or as you see fit in your
course.
A QSEN Competency Map and a BSN Essentials Map show you
how content connects with these important competencies.
Suggested Answers to the Critical Thinking Exercises in the Book
allow you to gauge whether students’ answers are on the right track by
providing main points that students are expected to address in the
answers.
Plus a Sample Syllabus and Learning Management System
Cartridges.
Resources for Students

An exciting set of free resources is available to help students review
material and become even more familiar with vital concepts. Students can
access all these resources at http://thePoint.lww.com/Eliopoulos10e using
the codes printed in the front of their textbooks.
Online Appendix A, Next Generation NCLEX-Style Case Studies

and Questions, and online Appendix B, Answers to Next
Generation NCLEX-Style Questions, provide practice answering
case-related questions in the Next Generation NCLEX format.
Watch & Learn Video Clips explain How to Assist a Person Who Is
Falling, Alternatives to Restraints, and the Five Stages of Grief. (Icons
in the textbook direct readers to relevant videos.)
Journal Articles offer access to current research available in Wolters
Kluwer journals.
Recommended Readings expand the network of available
information.
Plus Learning Objectives from the textbook.
A COMPREHENSIVE, DIGITAL,
INTEGRATED COURSE SOLUTION:
LIPPINCOTT® COURSEPOINT+
The same trusted solution, innovation, and unmatched support that you
have come to expect from Lippincott CoursePoint+ is now enhanced with
more engaging learning tools and deeper analytics to help prepare students
for practice. This powerfully integrated digital learning solution combines
learning tools, virtual simulation, real-time data, and the most trusted
nursing education content on the market to make curriculum-wide learning
more efficient and to meet students where they’re at in their learning. And
now, it’s easier than ever for instructors and students to use, giving them
everything they need for course and curriculum success!
Lippincott CoursePoint+ for Eliopoulos: Gerontological Nursing, 10th
edition includes the following:
Engaging course content provides a variety of learning tools to engage

students of all learning styles.
A more personalized learning approach gives students the content and
tools they need at the moment they need it, giving them data for more
focused remediation and helping to boost their confidence.
Powerful tools students need to learn the critical thinking and clinical
judgment skills that will help them become practice-ready nurses,
including:
Lippincott’s Adaptive Learning Powered by PrepU provides a
personalized learning experience for every student.
vSim for Nursing | Gerontology (also available for separate
purchase), a virtual simulation platform codeveloped by Laerdal
Medical and Wolters Kluwer, includes 12 gerontology patient
scenarios that correspond to the National League for Nursing
(NLN) Advancing Care Excellence for Seniors (ACES)
Unfolding Cases. vSim for Nursing | Gerontology helps students
develop clinical competence and decision-making skills as they
interact with virtual patients in a safe, realistic environment. vSim
for Nursing records and assesses student decisions throughout the
simulation, then provides a personalized feedback log
highlighting areas needing improvement.
Unparalleled reporting provides in-depth dashboards with several data
points to track student progress and help identify strengths and
weaknesses.
Unmatched support includes training coaches, product trainers, and nursing

education consultants to help educators and students implement
CoursePoint+ with ease.
Acknowledgments
There are many individuals who played important roles in the birth and
development of this book. I will always be grateful to Bill Burgower, a
Lippincott editor, who decades ago responded to my urging that the new
specialty of gerontological nursing needed resources by encouraging me to
write the first edition of Gerontological Nursing. Many fine members of the
Wolters Kluwer team have guided and assisted me since, including
Meredith Brittain, Senior Development Editor, who patiently guided the
process with her fine editorial skills; Michael Kerns, Acquisition Editor,
who brought encouragement and new perspectives; Molly Kennedy,
Editorial Assistant, and Vinoth Ezhumalai, Editorial Coordinator, who
assisted with navigating numerous details; and Sadie Buckallew, who
oversaw the production process. Also, much appreciation is offered to
Sherry Greenberg and Margaret Huryk for sharing their expertise with the
chapters they contributed.
Lastly, I am deeply indebted to those mentors and leaders in
gerontological care who generously offered encouragement and to the many
older adults who throughout the years have touched my life and showed me
the wisdom and beauty of aging. The insight these individuals provided
could have never been learned in a book!
Charlotte Eliopoulos
Brief Contents
UNIT 1 THE AGING EXPERIENCE

1 The Aging Population
2 Theories of Aging
3 Diversity
4 Life Transitions and Story
5 Common Aging Changes
UNIT 2 FOUNDATIONS OF
GERONTOLOGICAL NURSING
6 The Specialty of Gerontological Nursing
7 Holistic Assessment and Care Planning
8 Legal Aspects of Gerontological Nursing
9 Ethical Aspects of Gerontological Nursing
10 Continuum of Care in Gerontological Nursing
UNIT 3 HEALTH PROMOTION

11 Nutrition and Hydration
12 Sleep and Rest
13 Comfort and Pain Management
14 Safety
15 Safe Medication Use
UNIT 4 GERIATRIC CARE

16 Respiration
17 Circulation
18 Digestion and Bowel Elimination
19 Urinary Elimination
20 Reproductive System Health
21 Mobility
22 Neurologic Function
23 Vision and Hearing
24 Endocrine Function
25 Skin Health
26 Cancer
27 Mental Health Disorders
28 Delirium and Dementia
29 Living in Harmony With Chronic Conditions
UNIT 5 SETTINGS AND SPECIAL ISSUES IN

GERIATRIC CARE
30 Spirituality
31 Sexuality and Intimacy
32 Rehabilitative and Restorative Care
33 Acute Care
34 Long-Term Care
35 Family Caregiving
36 End-of-Life Care
Contents
UNIT 1 THE AGING EXPERIENCE

Views of Older Adults Through History
Characteristics of the Older Adult Population
Population Growth and Increasing Life Expectancy
Marital Status and Living Arrangements
Income and Employment
Health Insurance
Health Status
Implications of an Aging Population
Impact of the Baby Boomers
Provision of and Payment for Services
2 Theories of Aging
Biological Theories of Aging
Stochastic Theories
Nonstochastic Theories
Sociologic Theories of Aging
Disengagement Theory
Activity Theory
Continuity Theory
Subculture Theory
Age Stratification Theory
Psychological Theories of Aging
Developmental Tasks
Gerotranscendence
Nursing Theories of Aging
Functional Consequences Theory
Theory of Thriving
Theory of Successful Aging
Applying Theories of Aging to Nursing Practice
3 Diversity
Increasing Diversity of the Older Adult Population
Overview of Diverse Groups of Older Adults in the United
States
Hispanic Americans
Black Americans
Asian Americans
Jewish Americans
Native Americans
Muslims
Lesbian, Gay, Bisexual, Transgender, and Queer Older
Adults
Nursing Considerations for Culturally Sensitive Care of
Older Adults
Nurses’ Feelings and Attitudes
Patients’ Feelings and Attitudes
Ageism
Changes in Family Roles and Relationships
Parenting
Grandparenting
Loss of Spouse
Retirement
Loss of the Work Role
Reduced Income
Changes in Health and Functioning
Cumulative Effects of Life Transitions
Shrinking Social World
Awareness of Mortality
Responding to Life Transitions
Life Review and Life Story
Self-Reflection
Strengthening Inner Resources
Changes to the Body
Cells
Physical Appearance
Respiratory System
Cardiovascular System
Gastrointestinal System
Urinary System
Reproductive System
Musculoskeletal System
Nervous System
Sensory Organs
Endocrine System
Integumentary System
Immune System
Thermoregulation
Changes to the Mind
Personality
Memory
Intelligence
Learning
Attention Span
Nursing Implications of Age-Related Changes
UNIT 2 FOUNDATIONS OF
Development of Gerontological Nursing
Core Elements of Gerontological Nursing Practice
Evidence-Based Practice
Standards
Competencies
Principles
Gerontological Nursing Roles
Healer
Caregiver
Educator
Advocate
Innovator
Advanced Practice Nursing Roles
Self-Care and Nurturing
Following Positive Health Care Practices
Strengthening and Building Connections
Committing to a Dynamic Process
The Future of Gerontological Nursing
Utilize Evidence-Based Practices
Advance Research
Promote Integrative Care
Educate Caregivers
Develop New Roles
Balance Quality Care and Health Care Costs
Holistic Gerontological Care
Holistic Assessment of Needs
Health Promotion–Related Needs
Health Challenges–Related Needs
Requisites to Meet Needs
Gerontological Nursing Processes
Examples of Application
Applying the Holistic Model: The Case of Mrs. D
The Healer Role of the Nurse
Healing Characteristics
Laws Governing Gerontological Nursing Practice
Legal Risks in Gerontological Nursing
Malpractice
Confidentiality
Patient Consent
Patient Competency
Staff Supervision
Medications
Restraints
Telephone Orders
Do Not Resuscitate Orders
Advance Directives and Issues Related to Death and Dying
Elder Abuse
Legal Safeguards for Nurses
Philosophies Guiding Ethical Thinking
Ethics in Nursing
External and Internal Ethical Standards
Ethical Principles
Cultural Considerations
Ethical Dilemmas Facing Gerontological Nurses
Changes Increasing Ethical Dilemmas for Nurses
Measures to Help Nurses Make Ethical Decisions
Services in the Continuum of Care for Older Adults
Supportive and Preventive Services
Partial and Intermittent Care Services
Complete and Continuous Care Services
Complementary and Alternative Services
Matching Services to Needs
Settings and Roles for Gerontological Nurses
General
Nursing Homes
Adult Day Care
Support Groups
UNIT 3 HEALTH PROMOTION

Nutritional Needs of Older Adults
Quantity and Quality of Caloric Needs
Nutritional Supplements
Special Needs of Women
Hydration Needs of Older Adults
Promotion of Oral Health
Threats to Good Nutrition
Indigestion and Food Intolerance
Anorexia
Dysphagia
Constipation
Malnutrition
Addressing Nutritional Status and Hydration in Older
Adults
12 Sleep and Rest
Age-Related Changes in Sleep
Circadian Sleep–Wake Cycles
Sleep Stages
Sleep Efficiency and Quality
Sleep Disturbances
Insomnia
Nocturnal Myoclonus and Restless Legs Syndrome
Sleep Apnea
Medical Conditions That Affect Sleep
Drugs That Affect Sleep
Other Factors Affecting Sleep
Promoting Rest and Sleep in Older Adults
Pharmacologic Measures to Promote Sleep
Nonpharmacologic Measures to Promote Sleep
Pain Control
Comfort
Pain: A Complex Phenomenon
Prevalence of Pain in Older Adults
Types of Pain
Pain Perception
Effects of Unrelieved Pain
Pain Assessment
An Integrative Approach to Pain Management
Complementary Therapies
Dietary Changes
Medication
Comforting
14 Safety
Aging and Risks to Safety
Importance of the Environment to Health and Wellness
Impact of Aging on Environmental Safety and Function
Lighting
Temperature
Colors
Scents
Floor Coverings
Furniture
Sensory Stimulation
Noise Control
Bathroom Hazards
Fire Hazards
Psychosocial Considerations
The Problem of Falls
Risks and Prevention
Risks Associated With Restraints
Interventions to Reduce Intrinsic Risks to Safety
Reducing Hydration and Nutrition Risks
Addressing Risks Associated With Sensory Deficits
Addressing Risks Associated With Mobility Limitations
Monitoring Body Temperature
Preventing Infection
Suggesting Sensible Clothing
Using Medications Cautiously
Avoiding Crime
Promoting Safe Driving
Promoting Early Detection of Problems
Addressing Risks Associated With Functional Impairment
Effects of Aging on Medication Use
Polypharmacy and Interactions
Altered Pharmacokinetics
Altered Pharmacodynamics
Increased Risk of Adverse Reactions
Promoting the Safe Use of Drugs
Avoiding Potentially InappropriateDrugs: Beers Criteria
Reviewing Necessity and Effectiveness of Prescribed Drugs
Promoting Safe and Effective Administration
Providing Patient Teaching
Monitoring Laboratory Values
Alternatives to Drugs
Review of Selected Drugs
Analgesics
Antacids
Antibiotics
Anticoagulants
Anticonvulsants
Antidiabetic (Hypoglycemic) Drugs
Antihypertensive Drugs
Nonsteroidal Anti-inflammatory Drugs
Cholesterol-Lowering Drugs
Cognitive Enhancing Drugs
Digoxin
Diuretics
Laxatives
Psychoactive Drugs
UNIT 4 GERIATRIC CARE
16 Respiration
Effects of Aging on Respiratory Health
Respiratory Health Promotion
Selected Respiratory Conditions
Chronic Obstructive Pulmonary Disease
Pneumonia
Influenza
Lung Cancer
Lung Abscess
General Nursing Considerations for Respiratory Conditions
Recognizing Symptoms
Preventing Complications
Ensuring Safe Oxygen Administration
Performing Postural Drainage
Promoting Productive Coughing
Using Complementary Therapies
Promoting Self-Care
Providing Encouragement
17 Circulation
Effects of Aging on Cardiovascular Health
Cardiovascular Health Promotion
Proper Nutrition
Adequate Exercise
Cigarette Smoke Avoidance
Stress Management
Proactive Interventions
Cardiovascular Disease and Women
Selected Cardiovascular Conditions
Hypertension
Hypotension
Congestive Heart Failure
Pulmonary Emboli
Coronary Artery Disease
Hyperlipidemia
Arrhythmias
Peripheral Vascular Disease
General Nursing Considerations for Cardiovascular
Conditions
Prevention
Keeping the Patient Informed
Promoting Circulation
Providing Foot Care
Managing Problems Associated With Peripheral Vascular
Disease
Promoting Normality
Integrating Complementary Therapies
Effects of Aging on Gastrointestinal Health
Gastrointestinal Health Promotion
Selected Gastrointestinal Conditions and Related Nursing
Considerations
Dry Mouth (Xerostomia)
Dental Problems
Dysphagia
Hiatal Hernia
Esophageal Cancer
Peptic Ulcer
Cancer of the Stomach
Diverticular Disease
Colorectal Cancer
Chronic Constipation
Flatulence
Intestinal Obstruction
Fecal Impaction
Fecal Incontinence
Acute Appendicitis
Cancer of the Pancreas
Biliary Tract Disease
Effects of Aging on Urinary Elimination
Urinary System Health Promotion
Selected Urinary Conditions
Urinary Tract Infection
Urinary Incontinence
Bladder Cancer
Renal Calculi
Glomerulonephritis
General Nursing Considerations for Urinary Conditions
Effects of Aging on the Reproductive System
Reproductive System Health Promotion
Selected Reproductive System Conditions
Problems of the Female Reproductive System
Problems of the Male Reproductive System
21 Mobility
Effects of Aging on Musculoskeletal Function
Musculoskeletal Health Promotion
Promotion of Physical Exercise in All Age Groups
Exercise Programs Tailored for Older Adults
The Mind–Body Connection
Prevention of Inactivity
Nutrition
Selected Musculoskeletal Conditions
Fractures
Osteoarthritis
Rheumatoid Arthritis
Osteoporosis
Gout
Podiatric Conditions
General Nursing Considerations for Musculoskeletal
Conditions
Managing Pain
Preventing Injury
Promoting Independence
Effects of Aging on the Nervous System
Neurologic Health Promotion
Selected Neurologic Conditions
Parkinson’s Disease
Transient Ischemic Attacks
Cerebrovascular Accidents
General Nursing Considerations for Neurologic Conditions
Preventing Injury
Effects of Aging on Vision and Hearing
Sensory Health Promotion
Promoting Vision
Promoting Hearing
Assessing Problems
Selected Vision and Hearing Conditions and Related
Nursing Interventions
Visual Deficits
Hearing Deficits
General Nursing Considerations for Visual and Hearing
Deficits
24 Endocrine Function
Effects of Aging on Endocrine Function
Selected Endocrine Conditions and Related Nursing
Considerations
Diabetes Mellitus
Hypothyroidism
Hyperthyroidism
25 Skin Health
Effects of Aging on the Skin
Promotion of Skin Health
Selected Skin Conditions
Pruritus
Keratosis
Seborrheic Keratosis
Skin Cancer
Vascular Lesions
Pressure Injury
General Nursing Considerations for Skin Conditions
Promoting Normalcy
Using Alternative Therapies
26 Cancer
Aging and Cancer
Unique Challenges for Older Persons With Cancer
Explanations for Increased Incidence in Old Age
Risk Factors, Prevention, and Screening
Treatment
Conventional Treatment
Complementary and Alternative Medicine
Nursing Considerations for Older Adults With Cancer
Providing Patient Education
Promoting Optimum Care
Providing Support to Patients and Families
27 Mental Health Disorders
Aging and Mental Health
Promoting Mental Health in Older Adults
Selected Mental Health Conditions
Depression
Anxiety
Substance Abuse
Paranoia
Nursing Considerations for Mental Health Conditions
Monitoring Medications
Promoting a Positive Self-Concept
Managing Behavioral Problems
28 Delirium and Dementia
Delirium
Dementia
Alzheimer’s Disease
Other Dementias
Caring for Persons Living With Dementia
29 Living in Harmony With Chronic Conditions
Chronic Conditions and Older Adults
Goals for Chronic Care
Assessment of Chronic Care Needs
Maximizing the Benefits of Chronic Care
Selecting an Appropriate Physician
Using a Chronic Care Coach
Increasing Knowledge
Locating a Support Group
Making Smart Lifestyle Choices
Using Complementary and Alternative Therapies
Factors Affecting the Course of Chronic Care
Defense Mechanisms and Implications
Psychosocial Factors
Impact of Ongoing Care on the Family
The Need for Institutional Care
Chronic Care: A Nursing Challenge
UNIT 5 SETTINGS AND SPECIAL ISSUES IN

GERIATRIC CARE
30 Spirituality
Spiritual Needs
Love
Meaning and Purpose
Hope
Dignity
Forgiveness
Gratitude
Transcendence
Expression of Faith
Assessing Spiritual Needs
Addressing Spiritual Needs
Being Available
Honoring Beliefs and Practices
Providing Opportunities for Solitude
Promoting Hope
Assisting in Discovering Meaning in Challenging
Situations
Facilitating Religious Practices
Praying With and For
Attitudes Toward Sex and Older Adults
Realities of Sex in Older Adulthood
Sexual Behavior and Roles
Intimacy
Age-Related Changes and Sexual Response
Menopause as a Journey to Inner Connection
Symptom Management and Patient Education
Self-Acceptance
Andropause
Identifying Barriers to Sexual Activity
Unavailability of a Partner
Psychological Barriers
Medical Conditions
Erectile Dysfunction
Medication Adverse Effects
Cognitive Impairment
Promoting Healthy Sexual Function
Rehabilitative and Restorative Care
Living With Disability
Importance of Attitude and Coping Capacity
Losses Accompanying Disability
Principles of Rehabilitative Nursing
Functional Assessment
Interventions to Facilitate and Improve Functioning
Facilitating Proper Positioning
Assisting With Range of Motion Exercises
Assisting With Mobility Aids and Assistive Technology
Teaching About Bowel and Bladder Training
Maintaining and Promoting Mental Function
Using Community Resources
33 Acute Care
Risks Associated With Hospitalization of Older Adults
Surgical Care
Special Risks for Older Adults
Preoperative Care Considerations
Operative and Postoperative Care Considerations
Emergency Care
Infections
Discharge Planning for Older Adults
34 Long-Term Care
Development of Long-Term Institutional Care
Before the 20th Century
During the 20th Century
Lessons to Be Learned From History
Nursing Homes Today
Nursing Home Standards
Nursing Home Residents
Nursing Roles and Responsibilities
Other Settings for Long-Term Care
Assisted Living Communities
Community-Based and Home Health Care
Looking Forward: A New Model of Long-Term Care
The Older Adult’s Family
Identification of Family Members
Family Member Roles
Family Dynamics and Relationships
Scope of Family Caregiving
Long-Distance Caregiving
Protecting the Health of the Older Adult and Caregiver
Family Dysfunction and Abuse
Rewards of Family Caregiving
36 End-of-Life Care
Definitions of Death
Family Experience With the Dying Process
Supporting the Dying Individual
Stages of the Dying Process and Related Nursing
Interventions
Rational Suicide and Assisted Suicide
Physical Care Challenges
Spiritual Care Needs
Signs of Imminent Death
Advance Directives
Supporting Family and Friends
Supporting Through the Stages of the Dying Process
Helping Family and Friends After a Death
Supporting Nursing Staff
Appendix A: Next Generation NCLEX-Style Case Studies and
Questions Available on
Appendix B: Answers to Next Generation NCLEX-Style
Questions Available on
Index
Index of Selected Features
CASE STUDIES IN THIS BOOK

Next Generation NCLEX (NGN) Style Case Studies* in Chapters on
Clinical Topics
NGN-Style Case in Chapter 11, p. 159
*Questions and answers related to the NGN-Style Cases can be found in
online Appendices A and B.
Cases That Unfold Across Chapters
Unfolding Patient Stories: Julia Morales and Lucy Gray
Part 1: Chapter 3, p. 33
Part 3: Chapter 36, p.537
Unfolding Patient Stories: Millie Larsen
Unfolding Patient Stories: Sherman “Red” Yoder
Unfolding Patient Stories: Henry Williams
Cases Featured in Individual Chapters (Consider This Case)
Chapter 1: The Aging Population
Mr. and Mrs. Murdock, p. 7
Chapter 2: Theories of Aging
Mrs. Janus, p. 16
Chapter 3: Diversity
Mrs. C, p. 29
Chapter 4: Life Transitions and Story
Mrs. Ko, p. 47
Chapter 5: Common Aging Changes
Mr. G, p. 70
Chapter 6: The Specialty of Gerontological Nursing
Nurse Haley, p. 81
Chapter 7: Holistic Assessment and Care Planning
Mr. R, p. 98
Chapter 8: Legal Aspects of Gerontological Nursing
Resident of a nursing home who has fallen twice, p. 116
Chapter 9: Ethical Aspects of Gerontological Nursing
Mr. J, p. 127
Chapter 10: Continuum of Care in Gerontological Nursing
Mrs. Como, p. 134
Chapter 11: Nutrition and Hydration
Mrs. Valenti, p. 151
Chapter 12: Sleep and Rest
Mr. and Mrs. E, p. 168
Chapter 13: Comfort and Pain Management
Mr. O’Da, p. 179
Chapter 14: Safety
Mrs. Jensen, p. 195
Chapter 15: Safe Medication Use
Mr. Mansfield, p. 211
Chapter 16: Respiration
Mr. B, p. 244
Chapter 17: Circulation
Ms. U, p. 270
Chapter 18: Digestion and Bowel Elimination
Mr. C, p. 285
Chapter 19: Urinary Elimination
Mr. E, p. 296
Chapter 20: Reproductive System Health
Mr. and Mrs. C, p. 303
Chapter 21: Mobility
Mr. E, p. 320
Chapter 22: Neurologic Function
Mr. J, p. 345
Chapter 23: Vision and Hearing
Mr. and Mrs. R, p. 360
Chapter 24: Endocrine Function
Mr. Clarkson, p. 377
Chapter 25: Skin Health
Mrs. J, p. 385
Chapter 26: Cancer
Carrie S, p. 401
Chapter 27: Mental Health Disorders
Mrs. B, p. 415
Chapter 28: Delirium and Dementia
Mr. S, p. 434
Chapter 29: Living in Harmony With Chronic Conditions
Mrs. Johns, p. 444
Chapter 30: Spirituality
Mrs. McQueen, p. 458
Chapter 31: Sexuality and Intimacy
Mrs. W, p. 472
Chapter 32: Rehabilitative and Restorative Care
Mr. Mann, p. 491
Chapter 33: Acute Care
Mrs. H, p. 506
Chapter 34: Long-Term Care
Ms. Simmons, p. 516
Chapter 35: Family Caregiving
Mary K, p. 532
Chapter 36: End-of-Life Care
Mr. Angelos, p. 545
ASSESSMENT GUIDES
Assessment Guide 11-1: Nutritional Status, p. 157
Assessment Guide 13-1: Pain, p. 174
Assessment Guide 16-1: Respiratory Function, p. 233
Assessment Guide 17-1: Cardiovascular Function, p. 254
Assessment Guide 18-1: Gastrointestinal Function, p. 276
Assessment Guide 19-1: Urinary Function, p. 290
Assessment Guide 20-1: Reproductive System Health, p. 302
Assessment Guide 21-1: Musculoskeletal Function, p. 322
Assessment Guide 22-1: Neurologic Function, p. 338
Assessment Guide 23-1: Vision And Hearing, p. 351
Assessment Guide 25-1: Skin Status, p. 386
Assessment Guide 27-1: Mental Health, p. 407
Assessment Guide 30-1: Spiritual Needs, p. 454
Assessment Guide 31-1: Sexual Health, p. 470
NURSING CARE PLANS
Nursing Care Plan 7-1: Holistic Care for Mrs. D p. 100
Nursing Care Plan 16-1: The Older Adult With Chronic Obstructive
Pulmonary Disease, p. 238
Nursing Care Plan 17-1: The Older Adult With Heart Failure, p. 259
Nursing Care Plan 18-1: The Older Adult With Hiatal Hernia, p. 280
Nursing Care Plan 18-2: The Older Adult With Fecal Incontinence, p. 285
Nursing Care Plan 19-1: The Older Adult With Urinary Incontinence, p.
295
Nursing Care Plan 20-1: The Older Adult Recovering From Prostate
Surgery, p. 306
Nursing Care Plan 21-1: The Older Adult With Osteoarthritis, p. 325
Nursing Care Plan 22-1: The Older Adult With a Cerebrovascular Accident:
Convalescence Period, p. 343
Nursing Care Plan 23-1: The Older Adult With Open-Angle Glaucoma, p.
355
Nursing Care Plan 28-1: The Older Adult With Alzheimer’s Disease, p. 431
UNIT 1
The Aging Experience
2 Theories of Aging
3 Diversity
CHAPTER 1
The Aging Population
CHAPTER OUTLINE
Views of Older Adults Through History
Characteristics of the Older Adult Population
Population Growth and Increasing Life Expectancy
Health Insurance
Health Status
Implications of an Aging Population
LEARNING OBJECTIVES
After reading this chapter, you should be able to:
1. Explain the different ways in which older adults have been viewed
throughout history.
2. Describe characteristics of today’s older population in regard to:
Life expectancy
Marital status
Living arrangements
Income and employment
Health status
3. Discuss projected changes in future generations of older people and the

implications for health care.
TERMS TO KNOW
Comorbiditythe simultaneous presence of multiple chronic conditions
Compression of morbidityhypothesis that serious illness and decline can
be delayed or postponed so that an extended life expectancy results in
more functional, healthy years
Life expectancythe length of time that a person can be predicted to live
Life spanthe maximum years that a person has the potential to live
“Families forget their older relatives … most people become senile in old
age … Social Security provides every older person with a decent retirement
income … a majority of older people reside in nursing homes … Medicare
covers all health care–related costs for older people.” These and other
myths continue to be perpetuated about older people. Misinformation about
the older population is an injustice not only to this age group but also to
persons of all ages who need accurate information to prepare realistically
for their own senior years. Gerontological nurses must know the facts about
the older population to effectively deliver services and educate the general
public.
VIEWS OF OLDER ADULTS

THROUGH HISTORY
The members of the current older population in the United States have
offered the sacrifice, strength, and spirit that made this country great. They
were the proud GIs who served in wars, the brave immigrants who ventured
into a new country, the bold entrepreneurs who took risks that created
wealth and opportunities for employment, the campus rebels who advocated
for the rights of minorities, and the unselfish parents who struggled to give
their children a better life. They have earned respect, admiration, and
dignity. Today, older adults are viewed with positivism rather than
prejudice, knowledge rather than myth, and concern rather than neglect.
This positive view was not always the norm, however.
Historically, societies have viewed their elder members in a variety of
ways. In the time of Confucius, there was a direct correlation between a
person’s age and the degree of respect to which he or she was entitled. The
early Egyptians dreaded growing old and experimented with a variety of
potions and schemes to maintain their youth. Opinions were divided among
the early Greeks. Plato promoted older adults as society’s best leaders,
whereas Aristotle denied older people any role in governmental matters. In
the nations conquered by the Roman Empire, the sick and aged were
customarily the first to be killed. And, woven throughout the Bible is God’s
concern for the well-being of the family and desire for people to respect
elders (Honor your father and your mother … Exodus 20:12). Yet, the
honor bestowed on older adults was not sustained.
Medieval times gave rise to strong feelings regarding the superiority of
youth; these feelings were expressed in uprisings of sons against fathers.
Although England developed Poor Laws in the early 17th century that
provided care for the destitute and enabled older persons without family
resources to have some modest safety net, many of the gains were lost
during the Industrial Revolution. No labor laws protected persons of
advanced age; those unable to meet the demands of industrial work settings
were placed at the mercy of their offspring or forced to beg on the streets
for sustenance.
The first significant step in improving the lives of older Americans was
the passage of the Federal Old Age Insurance Law under the Social
Security Act in 1935, which provided some financial security for older
persons. The profound “graying” of the population started to be realized in
the 1960s, and the United States responded with the formation of the
Administration on Aging, enactment of the Older Americans Act, and the
introduction of Medicaid and Medicare, all in 1965 (Table 1-1).
TABLE 1-1 Publicly Supported Programs of Benefit to Older

Americans
Since that time, American society has demonstrated a profound
awakening of interest in older persons as their numbers have grown. A
more humanistic attitude toward all members of society has benefited older
adults, and improvements in health care and general living conditions
ensure that more people have the opportunity to attain old age and live
longer, more fruitful years in later adulthood than previous generations
(Fig. 1-1).
FIGURE 1-1 It is important for gerontological nurses to
be as concerned with adding quality to the lives of older
adults as they are with increasing the quantity of years.
CHARACTERISTICS OF THE OLDER

ADULT POPULATION
Older adults are generally defined as individuals aged 65 years and older.
At one time, all persons over 65 years of age were grouped together under
the category of “old.” Now it is recognized that much diversity exists
among different age groups in late life, and older individuals can be further
categorized as follows:
Youngest-old: 65 to 74 years
Middle-old: 75 to 84 years
Oldest-old: 85+
The profile, interests, and health care challenges of each of these
subsets can be vastly different. For example, a 66-year-old may desire
cosmetic surgery to stay competitive in the executive job market; a 74-year-
old may have recently remarried and want to do something about her dry
vaginal canal; an 82-year-old may be concerned that his arthritic knees are
limiting his ability to play a round of golf; and a 101-year-old may be
desperate to find a way to correct her impaired vision so that she can enjoy
television.
In addition to chronological age, or the years a person has lived since
birth, functional age is a term used by gerontologists to describe physical,
psychological, and social function; this is relevant in that how older adults
feel and function may be more indicative of their needs than their
chronological age. Perceived age is another term that is used to describe
how people estimate a person’s age based on appearance. Studies have
shown a correlation between perceived age and health, in addition to how
others treated older adults based on perceived age and the resultant health
of those older adults (Lin, Ankudowich, & Ebner, 2017).
How people feel or perceive their own age is described as age identity.
Some older adults will view peers of similar age as being older than
themselves and be reluctant to join senior groups and other activities
because they see the group members as “old people” and different from
themselves.
Any stereotypes held about older people must be discarded; if anything,
greater diversity rather than homogeneity will be evident. Further,
generalizations based on age need to be eliminated as behavior, function,
and self-image can reveal more about priorities and needs than
chronological age alone.
COMMUNICATION TIP
Not all persons of the same age will be similar in terms of language
style, familiarity with current terms, use of technology, education, and
life experience. Communication style and method must be based on
assessed language competency, style, and preference of the individual.
Population Growth and Increasing Life
Expectancy
There was a significant growth in the number of older people for most of
the 20th century. Except for the 1990s, the older population grew at a rate
faster than that of the total population under age 65. The U.S. Census
Bureau projects that a substantial increase in the number of individuals over
age 65 will occur between 2010 and 2030 due to the impact of the baby
boomers, who began to enter this group in 2011. In 2030, it is projected that
this group will represent nearly 20% of the total U.S. population.
Currently, persons older than 65 years represent more than 16% of the
population in the United States. This growth of the older adult population is
due in part to increasing life expectancy . Advancements in disease control
and health technology, lower infant and child mortality rates, improved
sanitation, and better living conditions have increased life expectancy for
most Americans. More people are surviving to their senior years than ever
before. In 1930, slightly more than 6 million persons were aged 65 years or
older, and the average life expectancy was 59.7 years. The life expectancy
in 1965 was 70.2 years, and the number of older adults exceeded 20
million. Life expectancy has now reached 78.7 years, with over 34 million
persons exceeding age 65 years (Table 1-2). Not only are more people
reaching old age, but they are living longer once they do; the number of
people in their 70s and 80s has been steadily increasing and is expected to
continue to increase. The population over age 65 is projected to almost
double by 2060, whereas the population over age 85 is projected to double
sooner—by the year 2040. The maximum life span currently is believed to
be 122 years for humans.
TABLE 1-2 Differences in Life Expectancy at Birth by Race,

Sex, and Hispanic Origin
Source: National Center for Health Statistics. (2019). Table A. Expectation of life by age, race,
Hispanic origin, race for non-Hispanic population, and sex: United States, 2017, National Vital
Statistics Reports, 68(7), 2019, Hyattsville, MD: National Center for Health Statistics. Retrieved
from https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68_07-508.pdf
KEY CONCEPT
More people are achieving and spending longer periods of time in old
age than ever before in history.
Although life expectancy has increased, it still differs by race and

gender, as Table 1-2 shows. From the late 1980s to the present, the gap in
life expectancy between white people and black people has widened
because the life expectancy of the black population has declined. The U.S.
Department of Health and Human Services attributes the declining life
expectancy of black people to heart disease, cancer, homicide, diabetes, and
perinatal conditions. This reality underscores the need for nurses to be
concerned with health and social issues of persons of all ages because these
impact a population’s aging process.
Whereas the gap in life expectancy has widened among the races, the
gap is narrowing between the sexes. Throughout the 20th century, the ratio
of men to women had steadily declined to the point where there were fewer
than 7 older men for every 10 older women. The ratio declined with each
advanced decade. However, in the 21st century, this trend is changing, and
the ratio of men to women is increasing.
Although living longer is desirable, of significant importance is the
quality of those years. More years to life means little if those additional
years consist of discomfort, disability, and a poor quality of life. This has
led to a hypothesis advanced by James Fries, a professor of medicine at
Stanford University, called the compression of morbidity (Fries, 1980;
Swartz, 2008). This hypothesis suggests that if the onset of serious illness
and decline would be delayed, or compressed, into a few years prior to
death, people could live a long life and enjoy a healthy, functional state for
most of their lives.
POINT TO PONDER
A higher proportion of older adults in our society means that younger
age groups will be carrying a greater tax burden to support the older
population. Should young families sacrifice to support services for older
adults? Why or why not?

The higher survival rates of women, along with the practice of women
marrying men older than themselves, make it no surprise that more than
half of women older than 65 years are widowed, and most of their male
contemporaries are married. Married people have a lower mortality rate
than do unmarried people at all ages, with men having a larger advantage.
Most older adults live in a household with a spouse or other family
member, although more than twice the number of women than men live
alone in later life. The likelihood of living alone increases with age for both
sexes. Most older people have contact with their families and are not
forgotten or neglected. Realities of the aging family are discussed in greater
detail in Chapter 35.
KEY CONCEPT
Women are more likely to be widowed and living alone in late life than
are their male counterparts.

The percentage of older people living below the poverty level has been
declining, with less than 10% now falling into this category. However, older
adults still do face financial problems. Most older people depend on Social
Security for more than half of their income (Box 1-1). Women and minority
groups have considerably less income than do white men. Although the
median net worth of older households is nearly twice the national average
because of the high prevalence of home ownership by elders, many older
adults are “asset rich and cash poor.” The recent decline in housing prices,
however, has made that asset a less valuable one for many older adults.
BOX 1-1 Social Security and Supplemental

Security Income
Social Security: a benefit check paid to retired workers of specific
minimum age (e.g., 65 years), disabled workers of any age, and spouses
and minor children of those workers. Benefits are not dependent on
financial need. It is intended to serve as supplement to other sources of
income in retirement.
Supplemental Security Income (SSI): a benefit check paid to persons
over age 65 and/or persons with disabilities based on financial need.
Although the percentage of the total population that older adults

represent is growing, they constitute a steadily declining percentage of
workers in the labor force. The withdrawal of men from the workforce at
earlier ages has been one of the most significant labor force trends since
World War II. There has been, however, a significant rise in the percentage
of middle-aged women who are employed, although there has been little
change in the labor force participation of women 65 years of age and older.
Most baby boomers are expressing a desire and need to continue working as
they enter retirement age.
CONSIDER THIS CASE

Mr. and Mrs. Murdock are both 67 years
of age and in good health. Mr. Murdock owns and manages several
investment properties that require him to maintain records, respond to
tenants’ service calls, and plan maintenance work. Mrs. Murdock is a
nurse who works in a community health center for children. Both of them
are working full-time and enjoy their work; however, they both admit that
their energy level is not what it used to be and that it takes them more time
to complete activities than it did in the past.
Although she does see positives to her work activities, Mrs. Murdock
feels that after many years of working, she deserves to relax and enjoy
other activities. When she suggests to her husband that he either retire or,
at the least, reduce his work activities so that they can enjoy this season of
life together, he is adamant about continuing to work because he believes
the income is beneficial to maintaining their lifestyle and he has no other
activities that he is interested in doing. She thinks he is being unrealistic,
claims that they can “get along just fine on Social Security,” and
repeatedly reminds him that they are at the age when people retire.
THINK CRITICALLY
1. What issues would be helpful for each of these individuals to
consider regarding their decision to retire or continue working?
2. What challenges could each of these individuals potentially face
if they continued to work for another 5 years? 10 years?
3. What actions could the Murdocks have taken in the past to face
their decisions about continued work or retirement differently?
4. What are the implications to society of people like the

Murdocks continuing to stay in the labor force?
KEY CONCEPT
Although Social Security was intended to be a supplement to other
sources of income for older adults, it is the main source of income for
more than half of all these individuals.
HEALTH INSURANCE
This decade has shaken the health care reimbursement systems in the
United States, and changes will be unfolding as the need to assure that
every American will have access to health care is balanced against
unsustainable costs to support that care. Passed in 1965 as Title 18 of the
Social Security Act, Medicare is the health insurance program for older
adults who are eligible for Social Security benefits. This federally funded
program primarily covers hospital and physician services with very limited
skilled home health and nursing home services under Part A. Preventive
services and nonskilled care (e.g., personal care assistance) are not covered.
To supplement the basic coverage, a person can purchase Medicare Part B,
which includes physician and nursing services, x-rays, laboratory and
diagnostic tests, influenza and pneumonia vaccinations, blood transfusions,
renal dialysis, outpatient hospital procedures, limited ambulance
transportation, immunosuppressive drugs for organ transplant recipients,
chemotherapy, hormonal treatments, and other outpatient medical
treatments administered in a doctor’s office. Part B also assists with the
payment of durable medical equipment, including canes, walkers,
wheelchairs, and mobility scooters for those with mobility impairments.
Prosthetic devices such as artificial limbs and breast prosthesis following
mastectomy, as well as one pair of eyeglasses following cataract surgery,
and oxygen for home use are also covered. Medicare Part C or Medicare
Advantage Plans give people the option of purchasing coverage through
private insurance plans to cover benefits not provided by Medicare Parts A
and B plus additional services. Although regulated and funded by the
federal government, these plans are managed by private insurance
companies. Some of these plans also include prescription drug benefits,
known as a Medicare Advantage Prescription Drug Plan or Medicare Part
D.
Persons who meet the income criteria can qualify for Medicaid, the
health insurance program for the poor of any age. This program was
developed at the same time as Medicare and is Title 19 of the Social
Security Act. Medicaid supplements Medicare for poor elderly individuals,
and most nursing home care is paid for by this program. Medicaid is
supported by federal and state funding. Provisions in the Affordable Care
Act expand Medicaid benefits to many older persons who did not
previously qualify for the program.
People of any age can purchase long-term care insurance to cover
health care costs not paid by Medicare or other health insurance. These
policies can provide benefits for home care, respite, adult day care, nursing
home care, assisted living, and other services. Policies vary in waiting
periods, amount of funds paid per day or month, and types of services that
qualify. Although beneficial, long-term care insurance has not attracted a
significant number of subscribers. Part of the reason for this is that policies
are expensive for older adults, and although less costly for persons of
younger age groups, younger and healthier individuals tend not to think
about long-term care.
Health Status
The older population experiences fewer acute illnesses than younger age
groups and a lower death rate from these problems. However, older people
who do develop acute illnesses usually require longer periods of recovery
and have more complications from these conditions.
Chronic illness is a major problem for the older population. Most older
adults have at least one chronic disease, and typically, they have multiple
chronic conditions, termed comorbidity , that requires them to manage the
care of several conditions simultaneously (Box 1-2). Chronic conditions
result in some limitations in activities of daily living and instrumental
activities of daily living for many individuals. The older the person is, the
greater the likelihood of difficulty with self-care activities and independent
living.
BOX 1-2 Ten Leading Chronic Conditions

Affecting Population Aged 65 Years and Older
1. Hypertension
2. High cholesterol
3. Arthritis
4. Ischemic heart disease
5. Diabetes
6. Chronic kidney disease
7. Heart failure
8. Depression
9. Alzheimer’s disease and dementia
10. Chronic obstructive pulmonary disease
Source: National Council on Aging. Retrieved January 3, 2020 from

https://d2mkcg26uvg1cz.cloudfront.net/wp-content/uploads/10-Common-Chronic-
Conditions-Older-Adults-ncoa.png
KEY CONCEPT
The chronic disorders most prevalent in the older population are ones
that can have a significant impact on independence and the quality of
daily life.
Chronic diseases are also the leading causes of death (Box 1-3). A shift
in death rates from various causes of death has occurred over the past three
decades; deaths from heart disease have declined, whereas those from
cancer have increased.
BOX 1-3 Leading Causes of Death for Persons

65 Years of Age and Older
Source: National Vital Statistics Reports, National Center for Health Statistics. (2019).
Deaths: Leading causes for 2017, 68(6). Table 1. Deaths, percentage of total deaths and death
rates for the 10 leading causes of death in selected age groups, by race and Hispanic origin
and sex: United States 2017, p. 18. Retrieved from
https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68_06-508.pdf
Concept Mastery Alert

When planning health education sessions for older adults that address the
health risks they face, the nurse should provide teaching about cancer
risks, screening, recognition, and treatment. Often, educational sessions
prioritize heart disease, although deaths from this cause are declining
while cancer deaths are rising.
Despite the advances in the health status of the older population,

disparities exist. Studies have found that older minorities have lower levels
of health and function. The number of older Hispanics, blacks, and Asians
admitted to nursing homes has been increasing, whereas the number of
older white nursing home residents has been declining (Harris-Kojetin et
al., 2019).
IMPLICATIONS OF AN AGING
POPULATION
The growing number of persons older than 65 years impacts health and
social service agencies and health care providers—including gerontological
nurses—that serve this group. As the older adult population grows, these
agencies and providers must anticipate future needs of services and
payment for these services.

In anticipating needs and services for future generations of older adults,
gerontological nurses must consider the realities of the baby boomers—
those born between 1946 and 1964—who will be the next wave of senior
citizens. Their impact on the growth of the older population is such that it
has been referred to as a demographic tidal wave. Baby boomers began
entering their senior years in 2011 and will continue to do so until 2030.
Although they are a highly diverse group, representing people as different
as Bill Clinton, Bill Gates, and Cher, they do have some clearly defined
characteristics that set them apart from other groups:
Most have children, but this generation’s low birth rate means that they
will have fewer biologic children available to assist them in old age.
They are better educated than preceding generations with slightly more
than half having attended or graduated from college.
Their household incomes tend to be higher than other groups, partly
due to two incomes (three out of four baby boomer women are in the
labor force), and most own their own homes.
They favor a more casual dress code than do previous generations of
older adults.
They are enamored with “high-tech” products, are likely to own a
computer, and spend several hours online daily.
Their leisure time is scarcer than other adults, and they are more likely
to report feeling stressed at the end of the day.
As inventors of the fitness movement, they exercise more frequently
than do other adults.
Some assumptions can be made concerning the baby boomer population

as senior adults. They are informed consumers of health care and desire a
highly active role in their care; their ability to access information often
enables them to have as much knowledge as their health care providers on
some health issues. They are most likely not going to be satisfied with the
conditions of today’s nursing homes and will demand that their long-term
care facilities be equipped with bedside Internet access, gymnasiums, juice
bars, pools, and alternative therapies. Their blended families may need
special assistance because of the potential caregiving demands of several
sets of stepparents and stepgrandparents. Plans for services and
architectural designs must take these factors into consideration.
COMMUNICATION TIP
Many baby boomers want to be informed health care consumers and
are comfortable communicating via e-mail and text messages. They
may prefer electronic appointment reminders and reports from
diagnostic tests rather than telephone calls, and they appreciate links
to fact sheets about their conditions and treatments. However, some
members of this generation are not tech savvy and prefer traditional
communication means, so it is important to ask about preferred style
of communication during the assessment.

The growing number of persons older than 65 years also impacts the
government that is the source of payment for many of the services older
adults need. The older population has higher rates of hospitalization,
surgery, and physician visits than other age groups (Table 1-3), and this care
is more likely to be paid by federal dollars than private insurers or older
adults themselves.
TABLE 1-3 Average Length of Hospital Stay
Source: Freeman, W. J. (2018). O verview of U.S. Hospital Stays in 2016: Variation by Geographic
Region. Table 1, Number, percentage, and rate of hospital stays, length of stay, and costs by patient
characteristics, 2016. Agency for Healthcare Research and Quality (AHRQ), Center for Delivery,
Organization, and Markets, Healthcare Cost and Utilization Project, National Inpatient Sample, 2016.
Retrieved from https://www.hcup-us.ahrq.gov/reports/statbriefs/sb246-Geographic-Variation-
Hospital-Stays.jsp
Less than 5% of the older population is in a nursing home, assisted

living community, or other institutional setting at any given time.
Approximately one in four older adults will spend some time in a nursing
home during the last years of their lives. Most people who enter nursing
homes as private pay residents spend their assets by the end of 1 year and
require government support for their care; most of the Medicaid budget is
spent on long-term care.
As the percentage of the advanced-age population grows, society will
face an increasing demand for the provision of and payment for services to
this group. In this era of budget deficits, shrinking revenue, and increased
competition for funding of other special interests, questions may arise about
the ongoing ability of the government to provide a wide range of services
for older adults. There may be concern that the older population is using a
disproportionate amount of tax dollars and that limits should be set.
Gerontological nurses must be actively involved in discussions and
decisions pertaining to the rationing of services so that the rights of older
adults are expressed and protected. Likewise, gerontological nurses must
assume leadership in developing cost-effective methods of care delivery
that do not compromise the quality of services to older adults.
KEY CONCEPT
Gerontological nurses need to be advocates in ensuring that cost-
containment efforts do not jeopardize the welfare of older adults.
BRINGING RESEARCH TO LIFE
The Impact of an Aging Population in the

Workplace
Source: White, M. S., Burns, C., & Conlon, H. A. (2018). Workplace Health
and Safety, 66(10), 493–498.
As a result of improved health and longer life expectancy, growing
numbers of older adults are working longer in the United States as well as
the rest of the world, and more are working full-time. Many older adults
view continued employment positively and work even if there is no
financial need. They desire to continue using their knowledge and skills,
which benefits their employers.
Older workers have been found to be more reliable, loyal, and satisfied.
They often are found to be more beneficial to employers due to the
flexibility in the hours they are willing to work.
Although working can provide physical and mental activity that
benefits older adults’ health, potential issues are associated with their
employment. The high prevalence of chronic conditions in these
individuals, as well as their greater risk for injuries, have safety
implications. Older workers, as compared to workers of all other ages, have
been found to have the highest rate of fatal injuries.
Nurses can play an important role in promoting best practices for a safe,
healthy workplace for older individuals. The nurses’ role could include
evaluating the ability of older workers to perform specific jobs, ensuring
capabilities are matched to job requirements, promoting ergo-friendly work
environments, counseling older employees on the importance of self-care,
and providing education related to health and safety. By promoting a
healthy, elder-friendly culture, nurses can aid older adults in maintaining
employment and encourage employers to hire and retain older workers.
PRACTICE REALITIES
You are in the break room of a hospital unit where several of the nurses are
eating the birthday cake of Nurse Clark who is celebrating her 66th
birthday. “I’m so glad to have coworkers like you and work that gives me a
sense of purpose,” Nurse Clark commented as she thanked everyone and
left the room.
Nurse Blake, in a low voice commented to the person sitting next to her,
“I just don’t get it. I’m half her age and this job drains me, so you know it’s
got to be taking its toll on her. Plus, we often get stuck doing the heavy
work that she can’t do.”
“I know she doesn’t have the physical capabilities that some others
may,” says Nurse Edwards, “but she sure is a storehouse of information and
the patients love her.”
“Yes, but that isn’t helping my back when I have to pick up the slack for
her,” responds Nurse Blake.
What are the challenges of having different generations in the
workplace? Should allowances be made for older workers, and if so, what
can be done to support these?
CRITICAL THINKING EXERCISES

1. What factors influence a society’s willingness to provide assistance to
and display a positive attitude toward older individuals (e.g., general
economic conditions for all age groups)?
2. List the anticipated changes in the characteristics of the older
population of the future, and describe the implications for nursing.
3. What problems may older women experience as a result of gender
differences in life expectancy and income?
4. What are some of the differences between older white and black
Americans?
Chapter Summary
Increases in life expectancy have resulted in persons over the age of 65
years now constituting 16% of the U.S. population. Although life
expectancy has increased in general, the black population has a lower life
expectancy than does the white population, reinforcing the importance of
addressing health and social problems throughout the life span to promote
longer and healthier life expectancies. In addition to extending life, there
also must be concern for the compression of morbidity to assure added
years of life are high-quality ones.
The primary source of health insurance for older adults is Medicare.
Medicaid provides supplemental insurance for individuals with low
incomes.
Although acute conditions occur at a lower rate in older adults than
younger age groups, when they do develop, they usually result in more
complications and longer periods for recovery. Chronic conditions are the
major health problems among older persons, with a majority being affected
by at least one chronic disease. Chronic conditions contribute to the leading
causes of death.
Baby boomers, a group composed of persons born between 1946 and
1964, have begun entering their senior years and are changing the profile of
the older population. They are highly diverse, are better educated, have
fewer children, have had higher incomes, and are greater users of
technology than previous generations. Gerontological nurses will be
challenged to recognize diversity among older adults as they assist these
individuals in health promotion and disease management activities.
Online Resources
National Center for Health Statistics
http://www.cdc.gov/nchs
Population Reference Bureau
https://www.prb.org/aging
United States Census Bureau
census.gov/topics/population.html
References
Fries, J. F. (1980). Aging, natural death, and the compression of morbidity. New England Journal of
Medicine, 303 (3), 130–135.
Harris-Kojetin, L., Sengupta, M., Lendon, J. P., Rome, V., Valverde, R., & Caffrey, C. (2019). Long-
term care providers and service users in the United States, 2015-2016. National Center for
Health Statistics. Vital and Health Statistics, 3 (43). Table IX, Nursing home residents by
selected characteristics and length of stay: United States 2016. Retrieved January 2, 2020 from
https://www.cdc.gov/nchs/data/series/sr_03/sr03_43-508.pdf
Lin, T., Ankudowich, E., & Ebner, N. C. (2017). Greater perceived similarity between self and own-
age others in older than young adults. Psychology and Aging, 32 (4), 377–387.
Swartz, A. (2008). James Fries: healthy aging pioneer. American Journal of Public Health, 98 (7),
1163–1166.
Recommended Readings
Recommended Readings associated with this chapter can be found on the
Web site that accompanies the book. Visit
http://thepoint.lww.com/Eliopoulos10e to access the list of recommended
readings and additional resources associated with this chapter.
CHAPTER 2
Theories of Aging
CHAPTER OUTLINE
Biological Theories of Aging
Stochastic Theories
Sociologic Theories of Aging
Activity Theory
Continuity Theory
Subculture Theory
Psychological Theories of Aging
Developmental Tasks
Gerotranscendence
Nursing Theories of Aging
Theory of Thriving
Applying Theories of Aging to Nursing Practice
LEARNING OBJECTIVES
1. Discuss the change in focus regarding learning about factors

influencing aging.
2. List the major biological theories of aging.
3. Describe the major psychosocial theories of aging.
4. Identify factors that promote a healthy aging process.
5. Describe the way in which gerontological nurses can apply theories of
aging to nursing practice.
TERMS TO KNOW
Agingthe process of growing older that begins at birth
Nonstochastic theoriesexplain biological aging as resulting from a
complex, predetermined process
Stochastic theoriesview the effects of biological aging as resulting from
random assaults from both the internal and external environment
For centuries, people have been intrigued by the mystery of aging and have
sought to understand it, some in hopes of achieving everlasting youth and
others seeking the key to immortality. Throughout history, there have been
numerous searches for a fountain of youth, the most famous being that of
Ponce de León. Ancient Egyptian and Chinese relics show evidence of
concoctions designed to prolong life or achieve immortality, and various
other cultures have proposed specific dietary regimens, herbal mixtures, and
rituals for similar ends. Ancient life extenders, such as extracts prepared
from tiger testicles, may seem ludicrous until they are compared with more
modern measures such as injections of embryonic tissue and Botox. Even
persons who would not condone such peculiar practices may indulge in
nutritional supplements, cosmetic creams, and exotic spas that promise to
maintain youth and delay the onset or appearance of old age.
No single known factor causes or prevents aging; therefore, it is
unrealistic to think that one theory can explain the complexities of this
process. Explorations into biological, psychological, and social aging
continue, and although some of this interest focuses on achieving eternal
youth, most sound research efforts aim toward a better understanding of the
aging process so that people can age in a healthier fashion and postpone
some of the negative consequences associated with growing old. In fact,
recent research has concentrated on learning about keeping people healthy
and active for a longer period of time, rather than on extending their lives in
a state of long-term disability. Recognizing that theories of aging offer
varying degrees of universality, validity, and reliability, nurses can use this
information to better understand the factors that may positively and
negatively influence the health and well-being of persons of all ages.
BIOLOGICAL THEORIES OF AGING
The process of biological aging differs not only from species to species but
also from one human being to another. Some general statements can be
made concerning anticipated organ changes, as described in Chapter 5;
however, no two individuals age identically (Fig. 2-1). Varying degrees of
physiologic changes, capacities, and limitations will be found among peers
of a given age group. Further, the rate of aging among different body
systems within one individual may vary, with one system showing marked
decline, while another demonstrates no significant change.
FIGURE 2-1 Aging is a highly individualized process,

demonstrated by the differences between persons of
similar ages.
KEY CONCEPT
The aging process varies not only among individuals but also within
different body systems of the same person.
To explain biological aging, theorists have explored many factors, both

internal and external to the human body, and have divided them into two
categories: stochastic and nonstochastic. Stochastic theories view the
effects of aging as resulting from random assaults from both the internal
and external environment over time. Nonstochastic theories see aging
changes resulting from a complex, predetermined process.
Stochastic Theories
Cross-Linking Theory
The cross-linking theory proposes that cellular division is threatened as a
result of radiation or a chemical reaction in which a cross-linking agent
attaches itself to a DNA strand and prevents normal parting of the strands
during mitosis. Over time, as these cross-linking agents accumulate, they
form dense aggregates that impede intracellular transport; ultimately, the
body’s organs and systems fail. An effect of cross-linking on collagen (an
important connective tissue in the lungs, heart, blood vessels, and muscle)
is the reduction in tissue elasticity associated with many age-related
changes.
Free Radicals and Lipofuscin Theories

The free radical theory suggests that aging is due to oxidative metabolism
and the effects of free radicals (Hayflick, 1985; Sousa-Victor, Neves, &
Jasper, 2016). Free radicals are highly unstable, reactive molecules
containing an extra electrical charge that are generated from oxygen
metabolism. They can result from normal metabolism, reactions with other
free radicals, or oxidation of ozone, pesticides, and other pollutants. These
molecules can damage proteins, enzymes, and DNA by replacing molecules
that contain useful biological information with faulty molecules that create
genetic disorder. It is believed that these free radicals are self-perpetuating;
that is, they generate other free radicals. Physical decline of the body occurs
as the damage from these molecules accumulates over time. However, the
body has natural antioxidants that can counteract the effects of free radicals
to an extent. Also, beta-carotene and vitamins C and E are antioxidants that
can offer protection against free radicals.
There has been considerable interest in the role of lipofuscin “age
pigments,” a lipoprotein by-product of oxidation that can be seen only
under a fluorescent microscope, in the aging process. Because lipofuscin is
associated with the oxidation of unsaturated lipids, it is believed to have a
role similar to that of free radicals in the aging process. As lipofuscin
accumulates, it interferes with the diffusion and transport of essential
metabolites and information-bearing molecules in the cells. A positive
relationship exists between an individual’s age and the amount of lipofuscin
in the body. Investigators have discovered the presence of lipofuscin in
other species in amounts proportionate to the life span of the species (e.g.,
an animal with one tenth the life span of a human being accumulates
lipofuscin at a rate approximately 10 times greater than human beings).
Wear and Tear Theories

The comparison of the body’s wearing down to machines that lost their
ability to function over time arose during the Industrial Revolution. Wear
and tear theories attribute aging to the repeated use and injury of the body
over time as it performs its highly specialized functions. Like any
complicated machine, the body will function less efficiently with prolonged
use and numerous insults (e.g., smoking, poor diet, and substance abuse).
In recent years, the effects of stress on physical and psychological
health have been widely discussed. Stresses to the body can have adverse
effects and lead to conditions such as gastric ulcers, heart attacks,
thyroiditis, and inflammatory dermatoses. However, because individuals
react differently to life’s stresses—one person may be overwhelmed by a
moderately busy schedule, whereas another may become frustrated when
faced with a slow, dull pace—the role of stress in aging is inconclusive.
Evolutionary Theories
Evolutionary theories of aging are related to genetics and hypothesize that
the differences in the aging process and longevity of various species occur
due to interplay between the processes of mutation and natural selection
(Arbuthmott, Promislow, & Moorad, 2016). Attributing aging to the process
of natural selection links these theories to those that support evolution.
There are several general groups of theories that relate aging to
evolution. The mutation accumulation theory suggests that aging occurs
due to a declining force of natural selection with age. In other words,
genetic mutations that affect children will eventually be eliminated because
the victims will not have lived long enough to reproduce and pass this to
future generations. Genetic mutations that appear late in life, however, will
accumulate because the older individuals they affect will have already
passed these mutations to their offspring.
The antagonistic pleiotropy theory suggests that accumulated mutant
genes that have negative effects in late life may have had beneficial effects
in early life. This is assumed to occur either because the effects of the
mutant genes occur in opposite ways in late life as compared with their
effects in early life or because a particular gene can have multiple effects—
some positive and some negative.
The disposable soma theory differs from other evolutionary theories by
proposing that aging is related to the use of the body’s energy rather than to
genetics. It claims that the body must use energy for metabolism,
reproduction, maintenance of functions, and repair, and with a finite supply
of energy from food to perform these functions, some compromise occurs.
Through evolution, organisms have learned to give priority of energy
expenditure to reproductive functions over those functions that could
maintain the body indefinitely; thus, decline and death ultimately occur.
KEY CONCEPT
Evolutionary theories suggest that aging “is fundamentally a product of
evolutionary forces, not biochemical or cellular quirks … a Darwinian
phenomenon, not a biochemical one” (Arbuthmott et al., 2016; Rose,
1998).
The evolutionary theory of aging proposes that people are living longer
due to the emphasis on natural selection through reproduction, whereas the
biogerontology theory of aging attributes longer life to the prevention and
control of pathogens.
Biogerontology
The study of the connection between aging and disease processes has been
termed biogerontology (Miller, 1997). Bacteria, fungi, viruses, and other
organisms are thought to be responsible for certain physiologic changes
during the aging process. In some cases, these pathogens may be present in
the body for decades before they begin to affect body systems. Although no
conclusive evidence exists to link these pathogens with the body’s decline,
interest in this theory has been stimulated by the fact that human beings and
animals have enjoyed longer life expectancies with the control or
elimination of certain pathogens through immunization and the use of
antimicrobial drugs.
Programmed/Apoptosis
Apoptosis is the process of programmed cell death that continuously occurs
throughout life due to biochemical events (Sodhi & Madan, 2020). In this
process, the cell shrinks and there is nuclear and DNA fragmentation,
although the membrane maintains its integrity. It differs from cell death that
occurs from injury in which there is swelling of the cell and loss of
membrane integrity. According to this theory, this programmed cell death is
part of the normal developmental process that continues throughout life.
Genetic Theories
Among the earliest genetic theories, the programmed theory of aging
proposes that animals and humans are born with a genetic program or
biological clock that predetermines the life span (Hayflick, 1965). Various
studies support this idea of a predetermined genetic program for life span.
For example, studies have shown a positive relationship between parental
age and filial life span. Additionally, studies of in vitro cell proliferation
have demonstrated that various species have a finite number of cell
divisions. Fibroblasts from embryonic tissue experience a greater number of
cell divisions than those derived from adult tissue, and among various
species, the longer the life span, the greater the number of cell divisions.
These studies supported the theory that senescence—the process of
becoming old—is under genetic control and occurs at the cellular level
(Kennedy, 2016; University of Illinois at Urbana-Champaign, 2002).
The error theory also proposes a genetic determination for aging. This
theory holds that genetic mutations are responsible for aging by causing
organ decline as a result of self-perpetuating cellular mutations, as
illustrated in Figure 2-2.
FIGURE 2-2 The error theory proposes a genetic
determination for aging.
Other theorists think that aging results when a growth substance fails to
be produced, leading to the cessation of cell growth and reproduction.
Others hypothesize that an aging factor responsible for development and
cellular maturity throughout life is excessively produced, thereby hastening
aging. Some hypothesize that the cell’s ability to function and divide is
impaired. Although minimal research has been done to support the theory,
aging may be the result of a decreased ability of RNA to synthesize and
translate messages.
POINT TO PONDER
What patterns of aging are apparent in your biological family? What can
you do to influence these?
Autoimmune Reactions
The primary organs of the immune system, the thymus and bone marrow,
are believed to be affected by the aging process. The immune response
declines after young adulthood. The weight of the thymus decreases
throughout adulthood, as does the ability to produce T-cell differentiation.
The level of thymic hormone declines after age 30 and is undetectable in
the blood of persons older than 60 years (Palmer, 2013). Related to this is a
decline in the humoral immune response, a delay in the skin allograft
rejection time, a reduction in the intensity of delayed hypersensitivity, and a
decrease in the resistance to tumor cell challenge. The bone marrow stem
cells perform less efficiently. The reduction in immunologic functions is
evidenced by an increase in the incidence of infections and many cancers
with age.
CONSIDER THIS CASE

You volunteer with a service organization
that is involved with several community projects. Mrs. Janus, one of the
volunteers you work with, shares with you and the other volunteers that
she and her husband have become distributors for “a fantastic product that
makes you look and feel younger.” She claims they have been using the
product for nearly a year and have seen significant improvements in the
way they look and feel. The couple is in their 70s and are attractive and
active.
Mrs. Janus passes out invitations to you and the other volunteers to
attend a meeting at their home to learn more about the products. Many of
the volunteers show considerable interest and indicate they will attend.
One of the volunteers then turns to you and says, “You’re a nurse. Do you
think these things work?”
THINK CRITICALLY
1. How can consumers judge the validity of claims of antiaging
products?
2. What evidence-based advice can be given to aging persons to

help them reduce the potential for some of the negative outcomes
of aging?
Some theorists believe that the reduction in immunologic activities also
leads to an increase in autoimmune response with age. One hypothesis
regarding the role of autoimmune reactions in the aging process is that the
cells undergo changes with age, and the body misidentifies these aged,
irregular cells as foreign agents and develops antibodies to attack them. An
alternate explanation for this reaction could be that cells are normal in old
age, but a breakdown of the body’s immunochemical memory system
causes it to misinterpret normal cells as foreign substances. Antibodies are
formed to attack and rid the body of these “foreign” substances, and cells
die.
Neuroendocrine and Neurochemical Theories

Neuroendocrine and neurochemical theories suggest that aging is the result
of changes in the brain and endocrine glands. Some theorists claim that
specific anterior pituitary hormones promote aging. Others believe that an
imbalance of chemicals in the brain impairs healthy cell division throughout
the body.
Radiation Theories
The relationship between radiation and age continues to be explored.
Research using rats, mice, and dogs has shown that a decreased life span
results from nonlethal doses of radiation. In human beings, repeated
exposure to ultraviolet light is known to cause solar elastosis, the “old age”
type of skin wrinkling that results from the replacement of collagen by
elastin. Ultraviolet light is also a factor in the development of skin cancer.
Radiation may induce cellular mutations that promote aging.
Nutrition Theories
The importance of good nutrition throughout life is a theme hard to escape
in our nutrition-conscious society. It is no mystery that diet impacts health
and aging. Obesity is shown to increase the risk of many diseases,
accelerate the aging process, and shorten life (NIDDK, 2019; Salvestrini,
Sell, & Lorenzini, 2019).
The quality of diet is as important as the quantity. Deficiencies of
vitamins and other nutrients and excesses of nutrients such as cholesterol
may cause various disease processes. Recently, increased attention has been
given to the influence of nutritional supplements on the aging process;
vitamin E, bee pollen, ginseng, gotu kola, peppermint, and curcumin are
among the nutrients believed to promote a healthy, long life (McCubrey et
al., 2017; Polyak et al., 2018). Although the complete relationship between
diet and aging is not well understood, enough is known to suggest that a
good diet may minimize or eliminate some of the ill effects of the aging
process.
KEY CONCEPT
It is beneficial for nurses to advise aging persons to scrutinize products
that claim to cause, stop, or reverse the aging process.
Environmental Theories
Several environmental factors are known to threaten health and are thought
to be associated with the aging process. The ingestion of mercury, lead,
arsenic, radioactive isotopes, certain pesticides, and other substances can
produce pathologic changes in human beings. Smoking and breathing
tobacco smoke and other air pollutants also have adverse effects. Finally,
crowded living conditions, high noise levels, and other factors are thought
to influence how we age.
POINT TO PONDER
Do you believe nurses have a responsibility to protect and improve the
environment? Why or why not?
SOCIOLOGIC THEORIES OF AGING

Sociologic theories address the impact of society on older adults and vice
versa. These theories often reflect the view held about older adults at the
time they were developed. The norms of society affected how the older
adult’s roles and relationships were viewed.
Developed by Elaine Cumming and William Henry, the disengagement
theory (Cumming, 1964; Cumming & Henry, 1961) has been one of the
earliest, most controversial, and most widely discussed theories of aging. It
views aging as a process in which society and the individual gradually
withdraw, or disengage, from each other, to the mutual satisfaction and
benefit of both. The benefit to individuals is that they can reflect and be
centered on themselves, having been freed from societal roles. The value of
disengagement to society is that some orderly means is established for the
transfer of power from the old to the young, making it possible for society
to continue functioning after its individual members die. The theory does
not indicate whether society or the individual initiates the disengagement
process.
Several difficulties with this concept are obvious, and this theory has
been discredited (Johnson, 2009). Many older persons desire to remain
engaged and do not want their primary satisfaction to be derived from
reflection on younger years. Senators, Supreme Court justices, college
professors, and many senior volunteers are among those who commonly
derive satisfaction and provide a valuable service to society by not
disengaging. Because the health of the individual, cultural practices,
societal norms, and other factors influence the degree to which a person will
participate in society during his or her later years, some critics of this theory
claim that disengagement would not be necessary if society improved the
health care and financial means of older adults and increased the
acceptance, opportunities, and respect afforded to them.
A careful examination of the population studied in the development of
the disengagement theory hints at its limitations. The disengagement pattern
that Cumming and Henry described was based on a study of 172 middle-
class persons between 48 and 68 years of age. This group was wealthier,
better educated, and of higher occupational and residential prestige than the
general aged population. No black people or chronically ill people were
involved in the study. Caution is advisable in generalizing findings for the
entire aged population based on fewer than 200 persons who are generally
not representative of the average aged person. (This study exemplifies some
of the limitations of gerontological research before the 1970s.) Although
nurses should appreciate that some older individuals may wish to disengage
from the mainstream of society, this is not necessarily a process to be
expected from all aging persons.
Activity Theory
At the opposite pole from the disengagement theory, the activity theory
asserts that an older person should continue a middle-aged lifestyle,
denying the existence of old age as long as possible, and that society should
apply the same norms to old age as it does to middle age and not advocate
diminishing activity, interest, and involvement as its members grow old
(Bengston, 2016; Havighurst, 1963). This theory suggests ways of
maintaining activity in the presence of multiple losses associated with the
aging process, including substituting intellectual activities for physical
activities when physical capacity is reduced, replacing the work role with
other roles when retirement occurs, and establishing new friendships when
old ones are lost. Declining health, loss of roles, reduced income, a
shrinking circle of friends, and other obstacles to maintaining an active life
are to be resisted and overcome instead of being accepted.
This theory has some merit. Activity is generally assumed to be more
desirable than inactivity because it facilitates physical, mental, and social
well-being. Like a self-fulfilling prophecy, the expectation of a continued
active state during old age may be realized to the benefit of older adults and
society. Because of society’s negative view of inactivity, encouraging an
active lifestyle among the aged is consistent with societal values. Also
supportive of the activity theory is the reluctance of many older persons to
accept themselves as old.
A problem with the activity theory is its assumption that most older
people desire and are able to maintain a middle-aged lifestyle. Some aging
persons want their world to shrink to accommodate their decreasing
capacities or their preference for less active roles. Many older adults lack
the physical, emotional, social, or economic resources to maintain active
roles in society. Aged people who are expected to maintain an active
middle-aged lifestyle on an income of less than half that of middle-aged
people may wonder if society is giving them conflicting messages. More
research and insights are needed regarding the effects on the older adults of
not being able to fulfill expectations to remain active.
Continuity Theory
The continuity theory of aging, also referred to as the developmental theory,
relates personality and predisposition toward certain actions in old age to
similar factors during other phases of the life cycle (Neugarten, 1964).
Personality and basic patterns of behavior are said to remain unchanged as
the individual ages. For instance, activists at 20 years of age will most
likely be activists at 70 years of age, whereas young recluses will probably
not be active in the mainstream of society when they age. Patterns
developed over a lifetime will determine whether individuals remain
engaged and active or become disengaged and inactive.
The recognition that the unique features of each individual allow for
multiple adaptations to aging and that the potential exists for a variety of
reactions gives this theory validity and support. Aging is a complex process,
and the continuity theory considers these complexities to a greater extent
than most other theories. Although the full implications and impact of this
promising theory are at the stage of research, it offers a reasonable
perspective. Also, it encourages the young to consider that their current
activities will lay a foundation for their own future old age.
KEY CONCEPT
Basic psychological patterns are consistent throughout the life span.
Subculture Theory
This theory views older adults as a group with distinct norms, beliefs,
expectations, habits, and issues that separate them from the rest of society
(Rose, 1965). Their formation of a subculture is a response to the negative
attitudes and treatment by society. Older persons are accepted by and are
more comfortable among, those of their own age group. A component of
this theory is the argument for social reform and greater empowerment of
the older populations so that their rights and needs can be respected.
The argument can be made that this theory is less relevant today than it
was in the 1960s, when it was first offered. In addition to the fact that there
is no research to support this theory, as the population of older adults
becomes more diverse, their needs become better addressed, and their
power is better recognized.

This theory, appearing in the 1970s, suggests that society is stratified by age
groups (Riley, Johnson, & Foner, 1972). Persons within a similar age group
generally have similar experiences, beliefs, attitudes, and life transitions
that offer them a unique shared history. New age groups are continually
being formed with the birth of new individuals; thus, the interaction
between society and the aging population is dynamic. As each group ages,
they have their own unique experience with and influence on society, and
there is an interdependence between society and the group.
POINT TO PONDER
How would you expect the aging experience of Generation X and
Generation Y to differ from that of the baby boomers and their parents?
PSYCHOLOGICAL THEORIES OF
AGING
Developmental Tasks
Psychological theories of aging explore the mental processes, behavior, and
feelings of persons throughout the life span, along with some of the
mechanisms people use to meet the challenges they face in old age. Among
these theories are those that describe the process of healthy psychological
aging as the result of the successful fulfillment of developmental tasks.
Developmental tasks are the challenges that must be met and adjustments
that must be made in response to life experiences that are part of an adult’s
continued growth through the life span.
Erik Erikson (1993) described eight stages through which human beings
progress from infancy to old age and the challenges, or tasks, that confront
individuals during each of these stages (Table 2-1). The challenge of old
age is to accept and find meaning in the life the person has lived; this gives
the individual ego integrity that aids in adjusting and coping with the reality
of aging and mortality. Feelings of anger, bitterness, depression, and
inadequacy can result in inadequate ego integrity (e.g., despair).
TABLE 2-1 Erikson’s Developmental Tasks

Refining Erikson’s description of old age tasks in the eighth stage of
development, Robert Peck (1968) detailed three specific challenges facing
the older adults that influence the outcome of ego integrity or despair:
Ego differentiation versus role preoccupation: to develop satisfactions

from oneself as a person rather than through parental or occupational
roles
Body transcendence versus body preoccupation: to find psychological
pleasures rather than become absorbed with health problems or
physical limitations imposed by aging
Ego transcendence versus ego preoccupation: to achieve satisfaction
through reflection on one’s past life and accomplishments rather than
be preoccupied with the finite number of years left to live
Robert Butler and Myrna Lewis (1998) outlined additional

developmental tasks of later life:
Adjusting to one’s infirmities

Developing a sense of satisfaction with the life that has been lived
Preparing for death
Gerotranscendence
Gerotranscendence is a recent theory that suggests aging entails a transition
from a rational, materialistic metaperspective to a cosmic and transcendent
vision (Tornstam, 2005). As people age, they are less concerned with their
physical bodies, material possessions, meaningless relationships, and self-
interests and instead desire a life of more significance and a greater
connection with others. There is a desire to shed roles and invest time in
discovering hidden facets of oneself.
POINT TO PONDER
How do you see examples of gerotranscendence in the lives of others
and yourself?
KEY CONCEPT
Nurses can promote joy and a sense of purpose in the older adults by
viewing old age as an opportunity for continued development and
satisfaction rather than a depressing, useless period of life.
NURSING THEORIES OF AGING

Although there are many classic theories that describe biological, social,
and psychological aging, none integrate all of these various dimensions of
aging into a holistic theory. Because nurses address all aspects of the
person, theories that offer the holistic perspective would be valuable in
guiding nursing care. In an effort to address this need, several nurses have
recently developed theories of aging.

The Functional Consequences Theory for Promoting Wellness in Older
Adults (Miller, 2014) integrates theories from aging and holistic nursing. It
holds that nurses can promote wellness by addressing individuals
holistically, recognizing the interconnection of body, mind, and spirit. The
consequences of age-related changes and risk factors can result in either
positive or negative functional consequences (i.e., wellness outcomes) for
older adults. Through interventions that promote wellness and alleviate or
reduce the impact of negative factors, nurses can promote positive
functional consequences.
Theory of Thriving
Based on their view that aging theories had been remiss in linking theories
together, the authors of this theory proposed that everything that impacts
people throughout their lives must be linked to create a holistic view of
aging (Haight, Barba, Tesh, & Courts, 2002). They based their theory on the
failure to thrive concept as it related to older adults in nursing homes
(Newbern & Krowchuk, 1994); the clinical characteristics of older persons
experiencing failure to thrive include disconnectedness, inability to find
meaning in life, problems with social relationships, and physical and
cognitive dysfunction. In contrast, thriving is possible when harmony exists
between individuals and their physical and human environments. The
process of thriving is continuous and enables aging individuals to find
meaning in life and adapt to changes. Recently, others have validated this
theory (Scott & Cohen, 2019). This theory reinforces the importance of
nurses considering the many factors that can impact health and quality of
life for older adults.

By integrating Roy’s adaptation model with the theory of
gerotranscendence and other aging literature, Flood (2005) attempted to
develop a nursing theory to guide the care of older adults. The Adaptation
Model of Nursing, developed by Sister Callista Roy, saw the individual as a
biopsychosocial being that continuously interacts with and adapts to the
changing internal and external environment (Arbuthmott et al., 2016; Roy
& Andrews, 2008). Roy viewed health on a continuum and involves the
person becoming an integrated, whole individual.
The Theory of Successful Aging not only considers successful aging in
terms of the older adult’s physical, mental, and spiritual well-being but also
includes the individual’s self-appraisal. Flood hypothesizes that people with
high levels of personal control and a positive affect will experience higher
levels of wellness in aging due to their ability to participate in health-
promoting activities. Higher levels of physical health, in turn, contribute to
deeper spirituality. These factors contribute to greater life satisfaction and
the aging individual’s positive perception of his or her status. By aiding
older adults in achieving high levels of health and personal control over
their lives, nurses can help aging individuals to have a positive view of their
lives, which in turn can promote their ability to cope and achieve greater
life satisfaction with age.
COMMUNICATION TIP
Nurses occasionally may hear people mentioning factors that
influence aging and suggestions for addressing them. This can range
from them stating that “there’s nothing that can be done about how we
age” to “taking supplement x can keep you from showing any signs of
aging.” These thoughts can result in people either not taking actions
that can influence a healthy aging process or risking their health and
finances on unproven antiaging products. Clarifying misconceptions is
beneficial. (See Box 2-1.)
BOX 2-1 Factors Contributing to a Long and

Healthy Life
DIET
A positive health state that can contribute to longevity is supported by
reducing saturated fats in the diet, limiting daily fat consumption to less
than 30% of caloric intake, avoiding obesity, decreasing the amount of
animal foods eaten, substituting natural complex carbohydrates for
refined sugars, and increasing the consumption of whole grains,
vegetables, and fruits.
ACTIVITY
Exercise is an important ingredient to good health. It increases strength
and endurance, promotes cardiopulmonary function, and has other
beneficial effects that can affect a healthy aging process.
PLAY AND LAUGHTER
Laughter causes a release of endorphins, stimulates the immune system,
and reduces stress. Finding humor in daily routines and experiencing joy
despite problems contribute to good health. It has been suggested since
the time of Solomon that “a cheerful heart is good medicine, but a
crushed spirit dries up the bones” (Proverbs 17:22).
FAITH
A strong faith, church attendance, and prayer are directly related to
lower rates of physical and mental illness. Religion and spirituality can
have a positive effect on the length and quality of life.
EMPOWERMENT
Losing control over one’s life can threaten self-confidence and diminish
self-care independence. Maximum control and decision-making can have
a positive effect on morbidity and mortality.
STRESS MANAGEMENT
It is the rare individual who is unaware of the negative consequences of
stress. The unique stresses that may accompany aging, such as the onset
of chronic conditions, retirement, deaths of significant others, and
change in body appearance, can have significantly detrimental effects.
Minimizing stress when possible and using effective stress management
techniques are useful interventions.
APPLYING THEORIES OF AGING TO

NURSING PRACTICE
The number, diversity, and complexity of factors that potentially influence
the aging process show that no one theory can adequately explain the cause
of this phenomenon. Even when studies have been done with populations
known to have a long life expectancy, such as the people of the Caucasus
region in southern Russia, longevity has not been attributable to any single
factor.
The biological, psychological, and social processes of aging are
interrelated and interdependent. Frequently, loss of a social role affects an
individual’s sense of purpose and speeds physical decline. Poor health may
force retirement from work, promoting social isolation and the development
of a weakened self-concept. Although certain changes occur independently
as separate events, most are closely associated with other age-related
factors. Wise nurses will be open-minded in choosing the aging theories
they use in the care of older adults; they will also be cognizant of the
limitations of these theories and aware that the validity of individual
theories could change over time as new insights are gained.
Nurses can adapt these theories by identifying elements known to
influence aging and using them as a foundation to promote positive
practices. Box 2-1 highlights some factors to consider in promoting a
healthy aging process.
In addition, gerontological nurses play a significant role in helping
aging persons experience health, fulfillment, and a sense of well-being. In
addition to specific measures that can assist the older adults in meeting their
psychosocial challenges (Box 2-2), nurses must be sensitive to the
tremendous impact their own attitudes toward aging can have on patients.
Nurses who consider aging as a progressive decline ending in death may
view old age as a depressing, useless period and foster hopelessness and
helplessness in older patients. However, nurses who view aging as a process
of continued development may appreciate late life as an opportunity to gain
new satisfaction and understanding, thereby promoting joy and a sense of
purpose in patients.
BOX 2-2 Assisting Individuals in Meeting the

Psychosocial Challenges of Aging
OVERVIEW
As individuals progress through their life span, they face challenges and
adjustments in response to life experiences called developmental tasks.
These developmental tasks can be described as:
Coping with losses and changes

Establishing meaningful roles
Exercising independence and control
Finding purpose and meaning in life
Satisfaction with oneself and the life one has lived is gained by
successfully meeting these tasks; unhappiness, bitterness, and fear of
one’s future can result from not adjusting to and rejecting the realities of
aging.
GOAL
Aging persons will express a sense of ego integrity and psychosocial
well-being.
ACTIONS
Learn about patients’ life stories; ask about family backgrounds,
faith, work histories, hobbies, achievements, and life experiences.
Encourage patients to discuss these topics, and listen with sincere
interest.
Build on lifelong interests and offer opportunities for patients to
experience new pleasures and interests.
Accept patients’ discussions of their regrets and dissatisfactions.
Help them to put these in perspective of their total lives and
accomplishments.
Encourage reminiscence activities between patients and their
families. Help families and staff to understand the therapeutic value
of reminiscence.
Respect patients’ faith and assist them in the fulfillment of spiritual
needs (e.g., help them locate a church of their religious affiliation,
request visits from clergy, pray with or for them, and obtain a Bible
or other religious book).
Use humor therapeutically.
If patients reside in an institutional setting, personalize the
environment to the maximum degree possible.
Recognize the unique assets and characteristics of each patient.
POINT TO PONDER
How would you evaluate the quality of the factors that promote
longevity in your own life?
Are Psycho-Behavioral Factors Accounting for

Longevity?
Source: Fernandez-Ballesteros, R., & Sanchez-Izquierdo, M. (2019).
Frontiers in Psychology, 10, 2516. doi: 10.3389/fpsyg.2019.02516.
Retrieved January 3, 2020 from
https://www.frontiersin.org/articles/10.3389/fpsyg.2019.02516/full
This article does a critical review of current factors believed to be
responsible for aging and longevity. The researchers identify two major
constructs that are considered as responsible for the length of life and health
of people: genetic or intrinsic (biomedical) factors, and environmental or
extrinsic factors. They believe there is a risk of misconceptions from this
classification because both types of factors are interdependent and influence
each other. In addition, psychological, social, economic, and cultural
characteristics are aspects of environmental factors, but these have not
received sufficient consideration. The authors hypothesize that cognitive
function, positive emotion and control, personality, and physical conditions
have a role in longevity and survival.
A review of research literature supports the authors’ hypothesis. They
suggest that the lack of research regarding the effects of behavioral and
psychological factors on longevity is more related to previous research
using traditional biomedical-based models for understanding longevity than
the lack of the effects of behavioral and psychological factors.
Because a variety of interrelated factors influence the aging process and
longevity, the nurse needs to consider all aspects of the individual––
physical, mental, emotional, socioeconomic––and to utilize a holistic
approach. The reality that nurses are concerned and involved with all
aspects of the individual could warrant their having a greater role in
research concerning the aging process and longevity.
PRACTICE REALITIES
You are presenting a class on positive health practices to a group at a local
senior center. At the end of the class, there is a lively discussion and one of
the older participants comments, “No matter what you do, how you age is
decided by your ancestors. My grandparents ate tons of fatty foods and
never exercised, and they lived to their 90s.”
“Oh, you’re wrong,” offers another member of the group. “I’ve been taking
a supplement that my neighbor sells that will override the problems you
inherited and I’m much healthier than my parents were at my age.”
How would you react to these comments and guide the discussion?

1. What disease processes are caused by or related to factors believed to
influence aging?
2. You are asked to speak to a community group regarding environmental
issues. What recommendations could you make for promoting a
healthy environment?
3. Think about everyday life in your community. What examples do you
see of opportunities to engage and disengage older adults?
4. What specific methods could you use to assist an older adult in
achieving ego integrity?
Chapter Summary
The aging process varies not only among individuals but among systems
within an individual. Biological aging has been described by stochastic
theories that view aging as the result of random assaults from the internal
and external environment and nonstochastic theories that view aging as
being a complex, predetermined process. Stochastic theories include the
cross-link, free radicals, lipofuscin, wear and tear, evolutionary, and
biogerontology theories. Nonstochastic theories describe the role of
apoptosis, genetic programming and mutations, autoimmune reactions,
neuroendocrines, neurochemicals, radiation, nutrition, and the environment
in the aging process.
Among the sociologic theories of aging, the disengagement theory is
one of the earliest, viewing aging as a process in which society and the
individual gradually withdraw, or disengage, from each other, to the mutual
satisfaction and benefit of both; this theory has fallen out of favor. The
activity theory proposes that to age in a healthy manner, individuals need to
stay active and engaged in society. Recognizing that not all individuals
disengage or are active in society as they age, the continuity theory suggests
that individuals will maintain the patterns of engagement in old age that
they practiced throughout their life span. Due to their distinct norms,
beliefs, and issues, some theorize that older adults constitute a subculture;
however, this theory may have less relevancy as the population of older
adults becomes increasingly diverse. The age stratification theory suggests
that the similarities among various age groups cause them to have unique
experiences and interactions with society. Psychological theories of aging
explore the mental processes, behavior, and feelings of persons throughout
the life span, along with some of the mechanisms people use to meet the
challenges they face in old age. Erikson described developmental tasks that
face people during each stage of life, with the task in old age to find ego
integrity versus despair. Peck developed this further by offering specific
challenges that older adults face as they strive for ego integrity; Butler and
Lewis also offered specific developmental tasks of late life. Some theorists
propose that with age, there is a transition from material to nonmaterial
concerns, known as gerotranscendence.
The journey of aging can be unique for each individual and impacted by
many factors. Therefore, nurses need to have a holistic focus in assessing,
planning, and providing care.
References
Arbuthmott, D., Promislow, D. E. L., & Moorad, J. A. (2016). Evolutionary theory and aging. In V.
L. Bengston & R. A. Settersten (Eds.), Handbook of theories of aging (3rd ed., pp. 113–136).
New York, NY: Springer.
Bengston, V. L. (2016). How theories of aging became social: Emergence of the sociology of aging.
In V. L. Bengston & R. A. Settersten (Eds.), Handbook of theories of aging (3rd ed., pp. 67–86).
New York, NY: Springer.
Butler, R. N., & Lewis, M. I. (1998). Aging and mental health (5th ed.). St. Louis, MO: Mosby.
Cumming, E. (1964). New thoughts on the theory of disengagement. In R. Kastenbaum (Ed.), New
thoughts on old age. New York, NY: Springer-Verlag.
Cumming, E., & Henry, E. (1961). Growing old: The process of disengagement. New York, NY:
Basic Books.
Erikson, E. (1993). Childhood and society (2nd ed.). New York, NY: Norton.
Flood, M. (2005). A mid-range nursing theory of successful aging. Journal of Theory Construction &
Testing, 9 (2), 35–39.
Haight, B. K., Barba, B. E., Tesh, A. S., & Courts, N. F. (2002). Thriving: A life span theory. Journal
of Gerontological Nursing, 28 (3), 14–22.
Havighurst, J. (1963). Successful aging. In R. H. Williams, C. Tibbitts, & W. Donahue (Eds.),
Processes of aging (Vol. 1, p. 299). New York, NY: Atherton Press.
Hayflick, L. (1965). The limited in vitro lifetime of human diploid cell strains. Experimental Cell
Research, 37 , 614–636.
Hayflick, L. (1985). Theories of biologic aging. Experimental Gerontology, 10 , 145–159.
Johnson, M. (2009). Spirituality, finitude, and theories of the life span. In V. I. Bengston, M.
Silverstein, N. M. Putney, & D. Gans (Eds.), Handbook of theories of aging (2nd ed., pp. 659–
674). New York, NY: Springer Publishing Co.
Kennedy, B. K. (2016). Advances in biological theories of aging. In V. L. Bengston R. A. Settersten
(Eds.), Handbook of theories of aging (3rd ed., pp. 107–112). New York, NY: Springer.
McCubrey, J. A., Lertpirilyapong, K., Steelman, L. S., Abrams, S. L., Yang, L. V., et al. (2017).
Effects of resveratrol, curcumin, berberine and other nutraceuticals on aging, cancer
development, cancer stem cells and microRNAs. Aging, 9 (6), 1477–1536.
Miller, R. A. (1997). When will the biology of aging become useful? Future landmarks in biomedical
gerontology. Journal of the American Geriatrics Society, 45 , 1258–1267.
Miller, C. A. (2014). Nursing for wellness in older adults (7th ed., pp. 40–45). Philadelphia, PA:
Wolters Kluwer Health/Lippincott Williams & Wilkins.
National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health.
(2019). Understanding adult overweight & obesity. Retrieved January 3, 2020 from
https://www.niddk.nih.gov/health-information/weight-management/adult-overweight-obesity
Neugarten, L. (1964). Personality in middle and late life. New York, NY: Atherton Press.
Newbern, V. B., & Krowchuk, H. V. (1994). Failure to thrive in elderly people: A conceptual
analysis. Journal of Advanced Nursing, 19 (5), 840–849.
Palmer, D. B. (2013). The effect of age on thymic function. Frontiers in Immunology, 4 (10).
Retrieved January 10, 2020 from frontiersin.org/articles/10.3389/fimmu.2013.00316/full
Peck, R. (1968). Psychological developments in the second half of life. In B. Neugarten (Ed.),
Middle age and aging (p. 88). Chicago, IL: University of Chicago.
Polyak, E., Ostrovsky, J., Peng, M., Dingley, S. D., Tsukikawa, M., et al. (2018). N-acetylcysteine
and vitamin E rescue animal longevity and cellular oxidate stress in pre-clinical models of
mitochondrial complex I disease. Molecular Genetics and Metabolism, 123 (4), 449–462.
Riley, M. M., Johnson, M., & Foner, A. (1972). Aging and society, vol. 3: A sociology of age
stratification. New York, NY: Russell Sage Foundation.
Rose, A. M. (1965). The subculture of the aging: A framework for research in social gerontology. In
A. M. Rose & W. Peterson (Eds.), Older people and their social worlds. Philadelphia, PA: F.A.
Davis.
Rose, M. R. (1998). Darwinian anti-aging medicine. Journal of Anti-Aging Medicine, 1 , 106.
Roy, C., & Andrews, H. A. (2008). The Roy adaptation model (3rd ed.). Upper Saddle River, NJ:
Prentice-Hall.
Salvestrini, V., Sell, C., & Lorenzini, A. (2019). Obesity may accelerate the aging process. Frontiers
in Endocrinology, 10 , 266. Retrieved January 3, 2020 from
https://www.frontiersin.org/articles/10.3389/fendo.2019.00266/full
Scott, M. J., & Cohen, A. B. (2019). Surviving and thriving: Fundamental social motives provide
purpose in life. Personality and Social Psychology Bulletin, 46 (6). Retrieved January 3, 2020
from https://journals.sagepub.com/doi/full/10.1177/0146167219883604
Sodhi, R. K., & Madan, J. (Eds.). (2020). Clinical perspectives and targeted therapies in apoptosis:
Drug discovery, drug delivery, and disease prevention. Salt Lake City, UT: Academic Press.
Sousa-Victor, P., Neves, J., & Jasper, H. (2016). Theories of stem cell aging. In Bengston, V. L. & R.
A. Settersten (Eds.), Handbook of theories of aging (3rd ed., pp. 153–172). New York, NY:
Springer.
Tornstam, L. (2005). Gerotranscendence: A developmental theory of positive aging. New York, NY:
Springer.
University of Illinois at Urbana-Champaign. (2002). Study backs theory that accumulating mutations
of “quiet” genes foster aging. Science News Daily. Retrieved January 2, 2020 from
http://www.sciencedaily.com/releases/2002/10/021015073143.htm
Recommended readings associated with this chapter can be found on the
CHAPTER 3
Diversity
CHAPTER OUTLINE
Increasing Diversity of the Older Adult Population
Overview of Diverse Groups of Older Adults in the United States
Hispanic Americans
Black Americans
Asian Americans
Jewish Americans
Native Americans
Muslims
Lesbian, Gay, Bisexual, Transgender, and Queer Older Adults
Nursing Considerations for Culturally Sensitive Care of Older
Adults
LEARNING OBJECTIVES
1. Describe projected changes in the diversity of the older population in

the United States.
2. Describe unique views of health and healing among major ethnic
groups.
3. Identify ways in which nursing care may need to be modified to
accommodate persons of diverse ethnic backgrounds.
TERMS TO KNOW
Bisexualsomeone sexually attracted to persons of both sexes
Cultureshared beliefs and values of a group: the beliefs, customs,
practices, and social behavior of a particular group of people
Ethnica group of people sharing a common racial, national, religious,
linguistic, or cultural heritage
Ethnogeriatricsthe effects of ethnicity and culture on the health and well-
being of older adults
Gaysomeone sexually attracted to a person of the same sex; homosexual
Lesbiana woman who is sexually attracted to other women
Racea group of people that share some biological characteristics
Transgendera person whose identity, appearance, and/or behavior varies
from that which the culture views as conventional for his or her gender;
sometimes referred to as transsexual or transvestite
INCREASING DIVERSITY OF THE

OLDER ADULT POPULATION
Population projections support the view that the older population in the
United States is becoming more ethnically and racially diverse. More than
one in five people in the United States speaks a language other than English
at home, with one third of these people speaking Spanish (U.S. Census
Bureau, 2018). In 2017, approximately 77% of older Americans were non-
Hispanic White, and it is projected that this population will decrease to 64%
by 2060 (Population Reference Bureau, 2019). During this same period,
there will be a dramatic growth in the number of Hispanic older adults, who
will represent nearly 20% of the older population. The percentage of black
individuals will grow from 9% to over 13% of the older population during
this time. By 2040, 34% of America’s older population will belong to a
minority racial or ethnic group (Administration on Aging, 2018). And, in
addition to racial and ethnic diversity, there will be growing numbers of
lesbian , gay , bisexual , and queer persons entering their senior years who
will present a unique set of challenges.
KEY CONCEPT
Ethnogeriatrics is a term used to describe the effects of ethnicity and
culture on the health and well-being of older adults. The American
Geriatrics Society has identified this as an important component of
geriatrics.
The growing diversity of the older population presents challenges for

gerontological nursing in providing culturally competent care. Essential to
the provision of culturally competent care is an understanding of:
The experiences of individuals of similar ethnic or racial backgrounds

Beliefs, values, traditions, and practices of various ethnic and racial
groups
Unique health-related needs, experiences, and risks of various ethnic
and racial groups and persons of similar sexual orientation
One’s own attitudes and beliefs toward people of various ethnic and
racial groups, and persons of similar sexual orientation, as well as
those attitudes of coworkers
Language barriers that can affect the ability of patients to communicate
health-related information, understand instructions, provide informed
consent, and fully participate in their care
An understanding of cultural, ethnic, and sexual orientation differences

can help to erase the stereotypes and biases that can interfere with effective
care and demonstrate an appreciation for the unique characteristics of each
individual.
OVERVIEW OF DIVERSE GROUPS OF

OLDER ADULTS IN THE UNITED
STATES
People from a variety of countries have ventured to America to seek a better
life in a new land. To an extent, they assimilated and adopted the American
way of life; however, the values and customs instilled in them by their
native cultures are often deeply ingrained, along with their language and
biological differences. The unique backgrounds of these newcomers to
America influence the way they react to the world around them and the
manner in which that world reacts to them. To understand the uniqueness of
each older adult encountered, consideration must be given to the influences
of ethnic origin.
Members of an ethnic or cultural group share similar history, language,
customs, and characteristics; they also hold distinct beliefs about aging and
older adults. Ethnic norms can influence diet, compliance with self-care
activities and medical treatments, trust in health care providers, and other
factors. The traditional responsibilities assigned to the aged of some ethnic
groups can afford them opportunities for meaningful roles and high status.
Studies of cultural influences on aging and effects on older adults have
been sparse but are growing. Experiences and observations can provide
insight into the unique characteristics of specific ethnic groups. Although
individual differences within a given ethnic group exist and stereotypes
should not be made, an understanding of the general traditional
characteristics of various ethnic groups can assist nurses in providing more
individualized and culturally sensitive care.
KEY CONCEPT
Although ethnic origin is important, the nurse needs to remember that
not all individuals conform to the beliefs, values, roles, and traditions of
the group of which they are a part. Stereotyping individuals who belong
to the same cultural or ethnic group runs contrary to individualized care.
Hispanic Americans
The term Hispanic encompasses a variety of Spanish-speaking persons in
America, including those from Spain, Mexico, Cuba, and Puerto Rico.
Hispanic people now represent approximately 8% of the older population in
the United States, but this percentage is expected to increase. Today, there
are approximately 60 million Hispanic people living in the United States,
and the fastest growing segment of the U.S. population is Hispanic
Americans older than 65 years.
KEY CONCEPT
The terms Hispanic and Latino are often used interchangeably, and in the
United States, Latino has become equated with Hispanics. However,
technically, there are differences in that Latino refers to persons from
countries once under Roman rule (e.g., Spain, Italy, and Portugal),
whereas Hispanic describes persons from countries once under Spanish
rule (e.g., Mexico, Central America, and most of South America).
Although Mexican people inhabited the Southwest United States for

decades before the arrival of the Pilgrims, most Mexican immigration
occurred during the 20th century as a result of the Mexican Revolution and
the poor economic conditions in Mexico. Poor economic conditions
continue to cause Mexicans to immigrate to the United States. The Mexican
population in this country totals more than 11 million, plus an estimated 5
million illegal immigrants; most reside in California and Texas (Passell &
Chon, 2019).
Most Puerto Rican immigration occurred after the United States granted
citizenship to all Puerto Ricans. After World War II, nearly one third of all
Puerto Rico’s inhabitants immigrated to America; in the 1970s, “reverse
immigration” began as growing numbers of Puerto Rican people left the
United States to return to their home island. More than 1 million Puerto
Ricans live in New York City, where most of them have settled.
Most Cuban immigrants are recent newcomers to America; the majority
of the greater than 2.3 million Cuban Americans fled Cuba after Castro
seized power. More than 66% of the Cuban American population resides in
Florida, with other large groups in New York and New Jersey. Among all
Hispanics, Cuban people are the most highly educated and have the highest
earnings.
KEY CONCEPT
Although cancer deaths have declined for all persons, they remain
disproportionately high among African Americans (National Cancer
Institute, 2019).
Some Hispanic people view states of health and illness as the actions of
God. By treating one’s body with respect, living a good life, and praying,
one will be rewarded by God with good health; in contrast, illness results
when one has violated good practices of living or is being punished by God.
Medals and crosses may be worn to facilitate well-being, and prayer may
play an important part in the healing process. Illness may be viewed as a
family affair, with multiple family members involved with the care of the
sick individual. Rather than using practitioners of Western medicine to treat
their health problems, some Hispanic persons may prefer traditional
practitioners, such as:
Curanderos: women who have special knowledge and charismatic

qualities
Sobadoras: persons who give massages and manipulate bones and
muscles
Espiritualistas: persons who analyze dreams, cards, and premonitions
Brujos: women who practice witchcraft
Senoras: older women who have learned special healing measures
The Hispanic population holds older relatives in high esteem. Old age is
viewed as a positive time in which the older person can reap the harvest of
his or her life. Hispanic people may expect that children will take care of
their aging parents, and families may try to avoid institutionalization at all
costs. Indeed, this group has a lower rate of nursing home use than the
general population; less than 7% of nursing home residents are Hispanic.
COMMUNICATION TIP
Nurses may find that English is a second language for some Hispanic
people, which becomes particularly apparent during periods of illness
when stress causes a retreat to the native tongue. An interpreter can be
used to facilitate communication. In addition, some Hispanic
individuals may be more comfortable when speaking (rather than
reading and writing) in English; this needs to be considered when
written instructions or questionnaires are used.
Although older Hispanic and non-Hispanic persons have similar types

of chronic conditions, older Hispanic individuals are generally less likely to
visit physicians or obtain preventive services (e.g., mammograms and
vaccines) and more likely to have difficulty obtaining care (U.S.
Department of Health and Human Services Office of Minority Health,
2019b).
Black Americans
Although approximately 13% of the entire U.S. population is black, only
9% of the older population is black. Most of this group is of African
descent. Historically, black Americans have experienced a lower standard
of living and less access to health care than their white counterparts. This is
reflected in the lower life expectancy of black Americans (see
demographics in Chapter 1). However, once a black individual reaches the
seventh decade of life, survival begins to equal that of similarly aged white
people.
To survive to old age is considered by some in this ethnic group to be a
major accomplishment that reflects strength, resourcefulness, and faith. In
addition, some black older adults:
Possess many health problems that have accumulated over a lifetime

due to a poor standard of living and limited access to health care
services
Are twice as likely to live in poverty compared with other older adults,
which can influence their utilization of health care services
May have a degree of caution in interacting with and using health
services, as a defense against prejudice (Ledford, 2019). May look to
family members for decision making and care rather than using formal
service agencies
Hypertension is a prevalent health problem among black Americans and

occurs at a higher rate than in any other group. One of the factors
responsible for hypertension is that only a minor decline in blood pressure
occurs during sleep, which increases the strain on the heart and vessels
(Yano et al., 2019). Blood pressure monitoring is an important preventive
measure for black clients (Fig. 3-1).
FIGURE 3-1 Blood pressure monitoring is an important

intervention for populations at higher risk for
hypertension.
In addition to hypertension, other health conditions that are prevalent in

the black population are heart disease, cancer, and diabetes. Blacks also
have a higher death rate from these diseases (Centers for Disease Control
and Prevention, 2017; U.S. Department of Health and Human Services
Office of Minority Health, 2019a).
According to the Centers for Disease Control and Prevention (2017,
2018, 2019), African American individuals have slightly higher rates of
smoking and obesity and higher death rates from heart disease, stroke,
cancer, asthma, influenza, pneumonia, diabetes, HIV/AIDS, and homicide
than the White and Hispanic populations (American Lung Association,
2019; Centers for Disease Control and Prevention, 2017, 2018, 2019;
Kaiser Family Foundation, 2019). To help prevent or control these causes of
morbidity and mortality, the nurse can recommend lifestyle changes (e.g.,
good nutrition, regular exercise, and effective stress management) and
regular health screening.
Asian Americans
More than 20 million Asian Americans reside in the United States,
representing more than 5% of the population. Asian Americans are a
diverse group composed of individuals from countries such as China, Japan,
the Philippines, Korea, Vietnam, and Cambodia. Asian Americans have a
lower unemployment rate than the national average (U.S. Bureau of Labor
Statistics, 2020).
Chinese Americans
Although Chinese laborers probably lived in America for centuries before
the mid-1800s, it was not until then that large-scale Chinese immigration
occurred. The largest American Chinese populations are in California, New
York, Texas, New Jersey, Massachusetts, and Illinois.
Care of the body and health are of utmost importance in traditional
Chinese culture, but their approach may be different from that of
conventional Western medicine (Box 3-1). People who adhere to these
beliefs use the senses (touching, listening to sounds, and detecting odors) to
assess medical problems rather than machinery or invasive procedures.
Modalities such as herbs and acupuncture, either alone or in combination
with Western modalities, are the treatments of choice for some Chinese
American individuals. In addition, some Chinese American women may
find it inappropriate to receive a physical examination or care from a man.
Nurses may need to observe more closely and ask specific questions (e.g.,
Can you describe your pain? How do you feel about the procedure you are
planning to have done? Do you have any questions?) to ensure that any
discomfort is identified.
BOX 3-1 Traditional Chinese Medicine

Traditional Chinese medicine, which has been practiced for thousands of
years, is based on a system of balance; illness is seen as an imbalance
and disharmony of the body. One of the theories that explains this
balance is that of yin and yang. Yin is the negative, female energy that is
represented by that which is soft, dark, cold, and wet. Organs associated
with yin qualities include the lungs, kidneys, liver, heart, and spleen.
Yang is the positive, male energy that is represented by that which is
hard, bright, hot, and dry. The gallbladder, small intestine, stomach,
colon, and bladder are yang organs. Daytime activity is considered more
of a yang state, whereas sleep is more of a yin state.
Chinese medicine also considers the body’s balance in relation to the
five elements or phases: wood (spring), fire (summer), earth (long
summer), metal (autumn), and water (winter).
Qi is the life force that circulates throughout the body in invisible
pathways called meridians. A deficiency or blockage of qi can cause
symptoms of illnesses. Acupuncture and acupressure can be applied to
various points along the meridians to stimulate the flow of qi.
In addition to acupuncture and acupressure, traditional Chinese
medicine uses herbs, massage, and therapeutic exercises (such as t'ai chi)
to promote a free flow of chi and achieve balance and harmony. These
modalities are gaining increasing acceptance in the United States, and
research supporting their effectiveness is growing rapidly.
CONSIDER THIS CASE

Mrs. C is a very traditional Chinese
woman who began living with her son and daughter-in-law 3 years ago,
after her husband’s death. Mrs. C and her husband had lived in a
“Chinatown” part of the city where they could freely communicate in
Chinese and interact with other Chinese individuals. She never developed
fluency in English and has experienced considerable difficulty
communicating with neighbors since moving into her son’s suburban
community. Mrs. C’s son has assimilated American values and practices
and has been critical of his mother for her traditional ways; he will not
acknowledge her when she speaks in Chinese and refuses to allow her to
cook Chinese foods. His wife is not Chinese but has been sympathetic to
the elder Mrs. C.
Last week, Mrs. C suffered a stroke that left her with weakness and
some aphasia. She will require care and supervision. Mrs. C’s son states
that he does not want his mother in a nursing home, but he is not sure he
can manage her; his wife says she is willing to take a leave of absence
from work and help care for her mother-in-law, if that is what her husband
wants.
THINK CRITICALLY
1. What problems do you anticipate for each of the family
members?
2. What arrangements can be made to assist the family?
3. How could you assist Mrs. C in preserving her ethnic practices?
KEY CONCEPT
Traditional Chinese medicine is based on the belief that the female
negative energy (yin) and the male positive energy (yang) must be in
balance.
In traditional Chinese culture, achieving old age is a blessing, and older

adults are held in high esteem. They are respected and sought for advice.
The family unit is expected to take care of its elder members; thus, older
adults may be a reluctant to use service agencies.
Japanese Americans
When they first immigrated to the United States, many Japanese Americans
held jobs as gardeners and farmers. Like Chinese Americans, Japanese
Americans today have a lower unemployment rate and a higher percentage
of professionals than the national average (Le, 2020; U.S. Bureau of Labor
Statistics, 2020). Currently, there are more than 1 million Japanese
Americans, most of whom live in California and Hawaii.
Although Japanese Americans have generally not tended to live in
separate subcommunities to the same extent as Chinese Americans, some
have preserved many of their traditions, including placing a high value on
the family, and expecting that families will take care of their elder members,
who are viewed with respect.
Similar to Chinese Americans, Japanese Americans may subscribe to
traditional health practices either to supplement or replace modern Western
technology, and nurses need to observe closely and ask questions to make
sure any issues are identified.
Other Asian Groups
In the early 1700s, Filipino people began immigrating to America, but most
Filipino immigrants arrived in the early 1900s to work as farm laborers. In
1934, an annual immigration quota of 50 was enacted; this quota stayed in
place until 1965.
In the early 1900s, Korean people immigrated to America to work on
plantations. Many of these individuals settled in Hawaii. Another large
influx of Koreans, many of whom were wives of American servicemen,
immigrated after the Korean War.
The most recent Asian American immigrants have been from Vietnam
and Cambodia. Most of these individuals came to the United States to seek
political refuge after the Vietnam War ended in 1975.
Many Asian Americans have strong family networks and the
expectation that family members will care for their older relatives at home,
resulting in low nursing home admission rates for this population.
POINT TO PONDER
What attitudes toward people of different cultures were you exposed to
as a child, and how have these molded your current attitudes?
Jewish Americans
Because they come from a variety of nations, with different customs and
cultures, Jewish people are not an ethnic group per se. However, the
strength of the Jewish faith forms a bond that crosses national origins and
gives this group a strong sense of identity and shared beliefs.
Scholarship is important in the Jewish culture; nearly 60% of all Jewish
Americans have graduated from college (Pew Research Center, 2019).
Approximately 6.9 million Jewish people, an estimated half of the world’s
Jewish population, reside in the United States, representing 2.2% of the
total population, with most living in urban areas of the Middle Atlantic
states (Jewish Virtual Library, 2020).
Religious traditions and holidays are important in the Jewish faith (Fig.
3-2). Sundown Friday to sundown Saturday is the Sabbath, and medical
procedures may be opposed during that time (exceptions may be made for
seriously ill individuals). Some Jewish people believe that the head and feet
should always be covered, so they may desire to wear a skullcap and socks
at all times. Orthodox Jews may oppose shaving. The Kosher diet (e.g.,
exclusion of pork and shellfish, prohibition of serving milk and meat
products at the same meal or from the same dishes) is a significant aspect of
Jewish religion and may be strictly adhered to by some. Fasting on holy
days, such as Yom Kippur and Tisha B’Av, and the replacement of matzo
for leavened bread during Passover may occur.
FIGURE 3-2 Celebrating religious holidays may be
important for certain groups, such as Jewish older adults.
Some Jewish people may desire rabbinical consultation for decisions
involving organ transplantation or life-sustaining measures. Certain rituals
may be practiced at death, such as members of the religious group washing
the body and sitting with it until burial, and autopsy may be opposed.
Family bonds and positive feelings for older adults are strong in Jewish
American culture, and illness can draw families together. Jewish Americans
have developed a network of community and institutional services for
Jewish American older adults; these services are geared toward providing
service while preserving Jewish tradition.
Native Americans
Native Americans (i.e., American Indians and Alaskan Natives) represent
5.4 million individuals. Native Americans inhabited North America for
centuries before Columbus explored the New World. An estimated 1 to 1.5
million Native Americans populated America at the time of the arrival of
Columbus; however, many battles with the new settlers during the next four
centuries reduced the Native American population to a quarter million. The
Native American population has been steadily increasing, with the U.S.
Census Bureau now showing approximately 6.7 million Native American
people who belong to more than 500 recognized tribes, nations, and
villages. The median age for the American Indian and Alaska Native
population is lower than for the general U.S. population. Only 8% of the
Native American population is older than 65 years, representing less than
1% of all older adults; however, they are one of the fastest-growing
minorities of the older adult population.
Most American Indians live in metropolitan areas (22% live on
reservations) with the highest populations found in California, Oklahoma,
Arizona, New Mexico, and Texas (U.S. Department of Health and Human
Services Office of Minority Health, 2018). The Indian Health Service, a
division of the U.S. Public Health Service, provides free, universal access to
health care to American Indians who reside on reservations. However, more
than half live in urban areas, where access to health care is inferior to that
on reservations. An estimated 150 Native American languages are spoken,
although most Native American people speak English as their first
language.
Traditional Native American culture emphasizes a strong reverence for
the Great Creator. A person’s state of health may be linked to good or evil
forces or to punishment for his or her acts. Those who adhere to Native
American medicine believe that a person must be in balance with nature for
good health and that illness results from imbalance.
KEY CONCEPT
Spiritual rituals, medicine men, herbs, homemade drugs, and mechanical
interventions are sometimes used by Native American people to treat
illness.
Native Americans may have close family bonds and may address each
other by their family relationship rather than by name (e.g., cousin,
daughter, uncle, and grandmother). The term elder is used to denote social
or physical status, not just age. Elders are often respected and viewed as
leaders, teachers, and advisors to the young, although younger members,
some of whom are less traditional, feel that the advice of their elders is not
as relevant in today’s world and therefore break from this tradition. Some
Native American people strongly believe that individuals have the right to
make decisions affecting their lives. The typical nursing assessment process
may be offensive to the traditional Native American patient, who may view
probing questions, validation of findings, and documentation of responses
as inappropriate and disrespectful behaviors during the verbal exchange. A
Native American patient may be ambivalent about accepting services from
agencies and professionals. Such assistance has provided many social,
health, and economic benefits to improve the life of Native Americans, but
it also conflicts with traditional Native American beliefs of being useful,
doing by oneself, and relying on spiritual powers to chart the course of life.
Native American patients often remain calm and controlled, so nurses need
to observe closely and ask questions to make sure any issues are identified.
Various tribes may have specific rituals that are performed at death,
such as burying certain personal possessions with the individual. Consulting
with members of the specific tribe to gain insight into special rituals during
sickness and at death would be advantageous for nurses working with
Native American populations.
The last part of the 20th century saw a rise in certain preventable
diseases among Native Americans. As compared to other racial and ethnic
groups, Native Americans have higher rates of heart disease, cancer,
diabetes, stroke, cirrhosis, and chronic lower respiratory disease (Indian
Health Services, 2019; National Indian Council on Aging, 2019). The
cancer survival rate among Native Americans is the lowest of any U.S.
population. Nurses must promote health education and early screening to
aid this population in reducing risks and identifying health conditions early.
Muslims
There are over a billion Muslims in the world who share a common culture
based on the belief that Allah is God, and Muhammad is his messenger.
Muslim customs and traditions are centered on religious beliefs and
customs derived from Muslim’s holy book, the Quran.
Older adults, who represent less than 1% of the Muslim population, are
traditionally viewed with high esteem and are treated with respect; mothers
are especially honored. The tradition has been for older Muslims to be cared
for by their families, although this is changing as more Muslim women
enter the workforce.
Devout Muslims eat only meat that has been slaughtered according to
religious requirements (halal meat) and do not eat pork or pork products.
Water typically is consumed with every meal. Muslim patients who adhere
strictly to fasting may not take medications during fasting times; sensitivity
to this practice may require an adjustment of medication administration
times.
A Muslim patient may prefer to be cared for by a person of the same
sex and to have exposure of the body kept to a minimum. Traditionally,
Muslims do not like to have their heads touched unless doing so is part of
an examination or treatment.
Devout Muslim patients who are unconscious or terminally ill should
be positioned so their faces are turned to Mecca, which typically is west to
northwest. Family and friends may recite the Quran or prayers in front of
the patient or in a nearby room. If a chapel is provided for praying, it is
important that no crosses or icons be present. The family should be asked if
they would like their religious leader to visit.
POINT TO PONDER
In what ways do you honor and celebrate your unique heritage?
Lesbian, Gay, Bisexual, Transgender, and Queer

Older Adults
Despite the growing awareness and acceptance of lesbian, gay, bisexual,
transgender, and queer (LGBTQ) persons in society as a whole, there has
been minimal consideration of the challenges and needs of these individuals
when they reach late life. In fact, they are referred to as a largely invisible
population (Kim, Fredriksen-Goldsen, Bryan, & Muraco, 2017). However,
this population is growing; as much as 10% of the U.S. population
identifies as being lesbian, gay, bisexual, or transgender; the LGBTQ
population is projected to double by 2030.
This generation of older adults lived through a period when
considerable prejudice and discrimination existed against persons who were
LGBTQ; therefore, these individuals may not divulge their sexual
orientation when seeking health services. Studies have found that LGBTQ
older adults in community and long-term care settings reported being
fearful of rejection and neglect by caregivers, not being accepted by other
residents, and being forced to hide their sexual orientation (Caceres,
Travers, Primiano, Luscombe, & Dorsen, 2019). In addition, the following
are true of LGBTQ elderly (Advocacy and Services for LGBT Elders,
2019):
Nearly one third report having poor health and lacking a regular
medical provider.
There are higher rates of poor physical and mental health than in non-
LGBTQ elderly.
They have higher rates of smoking and alcohol consumption as
compared to the non-LGBTQ population.
Over 40% report having a disability.
Recent years have noted progress in addressing the needs of the

LGBTQ population. The American Association of Retired Persons has
created an online LGBT community, the American Society on Aging has an
LGBT Aging Issues Network, and the Joint Commission has added respect
for sexual orientation to the rights of residents of assisted living
communities and skilled nursing homes. In addition, Advocacy and
Services for Lesbian, Gay, Bisexual, and Transgender Elders (SAGE) and
the Movement Advancement Project (MAP) have been aggressively
addressing policy and regulatory changes that are needed to address the
needs of this population.
Nurses need to appreciate that the LGBTQ elder population represents
unique individuals with different experiences, profiles, and needs. As with
any patient, individualized approaches are essential, and stereotypes need to
be avoided. Nurses should inquire about partners these patients may desire
to have involved with care and should include these partners as desired by
the patients. Further, nurses need to ensure that LGBTQ individuals can
receive services without prejudice, stigmatization, or threat.
Unfolding Patient Stories: Julia Morales and

Lucy Grey • Part 1
Julia Morales, age 65, and Lucy Grey, age 73,
are partners who have been together for more than 25 years. Julia’s son,
Neil, age 42, also provides support. Julia is undergoing treatment for lung
cancer. What strengths and challenges should the nurse consider for an
older, retired couple whose sexual orientation is not heterosexual? How
can the nurse identify the unique needs of this couple to provide holistic
and culturally competent care? What culturally specific resources would
be available to address the unique needs of Julia and Lucy? (The story of
Julia Morales and Lucy Grey continues in Chapter 8.)
Care for Julia, Lucy, and other patients in a realistic virtual
environment: (thepoint.lww.com/vSimGerontology). Practice
documenting these patients’ care in DocuCare
(thepoint.lww.com/DocuCareEHR).
NURSING CONSIDERATIONS FOR

CULTURALLY SENSITIVE CARE OF
OLDER ADULTS
Numerous minority, ethnic, or cultural groups that have not been mentioned
also possess unique histories, beliefs, and practices. Rather than viewing
differences as odd and forcing patients to conform to “American” traditions,
nurses should respect and preserve the beauty of the diverse beliefs, values,
relationships, roles, and traditions associated with cultural and ethnic
identity.

The effectiveness of care can be largely influenced by the initial impression
made by the nurse. Nurses need to reflect on any personal feelings or
attitudes that could affect the nurse–patient relationship or convey a
prejudicial attitude. For example, if a nurse’s religion teaches that
homosexuality is abnormal and sinful, the nurse may display discomfort in
nurse–patient interactions with patients who are gay. As a result, these
patients may sense prejudice and be reluctant to share all aspects of their
history and problems. Likewise, if the nurse has had limited experiences
with persons of a different racial group, he or she may appear uneasy or
unnatural in communicating with those individuals. To assist in preventing
personal feelings from interfering with the professional relationship, nurses
should reflect on their feelings and discuss these issues with other
professionals.
Nurses need to be careful not to stereotype patients based on race ,
ethnicity, sexual orientation, or other factors. All patients should be
addressed by their last name (e.g., Ms. Smith, Mr. Jones) unless they
request otherwise. Recognizing that some people might be guarded with
personal information based on their cultural or ethnic backgrounds, nurses
should explain to all patients the reason various questions will be asked
during the interview. Ample time should be allotted for patients to share
their histories and cultural or religious practices. The use of touch (e.g.,
patting the person’s hand or touching an arm) often demonstrates caring and
assists in putting a person at ease; however, be aware that in some cultural
groups, being touched by a stranger is viewed as inappropriate. Similarly,
providing less than 1.5 ft of spatial distance between the nurse and the
patient during the interview can be too close for some patients and make
them uncomfortable. This reinforces the importance of nurses becoming
familiar with the beliefs and practices of various groups.
Nurses should accommodate dietary preferences, make adaptations for
special practices, and understand unique ways of managing illness.
Consideration should be given to differences in the expression of pain, fear,
and other feelings. Reactions to illness and care can vary. For example, one
person may view illness as punishment for wrongdoing; however, another
may see it as part of the normal human experience. Some individuals may
desire family members or traditional healers to actively participate in their
care, whereas others may not.
If nurses are unfamiliar with a particular group, they should invite the
patient and the family members to educate them, or they should contact
churches or ethnic associations (e.g., Polish National Alliance, Celtic
League, Jewish Family and Children’s Services, and Slovak League of
America) for interpreters or persons who can serve as cultural resources.
One powerful means to learn about cultural influences for individual
patients is to ask them to describe their life stories (see Chapter 4). Nurses
convey sensitivity and caring when they try to recognize and support
patients’ ethnic and cultural backgrounds. Nurses also become enriched by
gaining an appreciation and understanding of the various ethnic groups.
The U.S. Department of Health and Human Services has developed
standards for culturally and linguistically appropriate services that can
guide clinical settings in working with diverse populations; their Web site
can be accessed at http://minorityhealth.hhs.gov.
The increasing diversity of older adults will affect services in a variety
of ways. Among the needs that could present are:
Institutional meal planning that incorporates ethnic foods

Multilingual health education literature
Readily available translators
Provisions for celebration of holidays (e.g., Chinese New Year, St.
Patrick’s Day, Black History Month, Greek Orthodox Easter)
Special interest groups for residents of long-term care facilities and
assisted living communities

An uncomfortable reality that a nurse may face is a prejudicial comment by
a patient. Because patients reflect the society in which they live, and with
prejudices unfortunately being a part of society, the nurse is likely to
encounter prejudiced patients. For example, a patient may refuse to receive
care from a nurse of a different race. At times, persons who are highly
stressed or who have dementias may use offensive racial language.
Understandably, this can be hurtful to the nurse. The individual patient and
situation, as well as the nurse’s experience in handling these situations, will
determine the action the nurse should take; options include requesting the
patient not to make the comment, asking the patient if he or she would
prefer to have someone else assigned as the nurse, asking to be reassigned,
and discussing the situation with one’s manager.
Nurses need to ensure that cultural, religious, and sexual orientation
differences of older adults are understood, appreciated, and respected.
Demonstrating this sensitivity honors the older adult’s unique history and
preserves the familiar and important. The challenges faced by older adults
need not be compounded by insensitive or prejudicial behaviors by nurses.
Care of LGBTQ Older Adults: What Geriatric

Nurses Must Know
Source: Caceres, B. A. (2019). Geriatric Nursing, 40(3), 342–343.
Through their code of ethics, nurses are called to integrate social justice
into their practice. Although promoting health equity for all people is part
of nurses’ commitment, there is evidence that the health needs of LGBTQ
individuals are largely ignored; this is true to a greater extent within
geriatric nursing. About one fifth of LGBTQ older adults hide their sexual
orientation from health care providers due to fear of how this knowledge
would affect their care. Nurses have been found to have little understanding
of LGBTQ health issues, and many hold negative attitudes toward LGBTQ
people that have the potential for impacting the care of these individuals.
Studies have shown that providers’ discrimination, lack of knowledge, and
reduced health care utilization were among the factors contributing to
negative health outcomes in LGBTQ older adults.
The article suggests that geriatric nurses examine their own biases,
learn more about LGBTQ health, and assure inclusive care environments
for LGBTQ people. Being the largest group of health care providers and the
health care professionals with whom people have the most direct contact,
nurses can make a difference and set an example. Nurses should learn about
LGBTQ issues, set an example of nondiscriminatory care, and teach other
providers of care about these issues. Gaining an understanding of
terminology (e.g., sexual orientation, gender, and transgender) can aid in
building trust between LGBTQ individuals and nurses. Recognizing that
similarities in sexual orientation and gender identity do not make all older
LGBTQ persons alike is another important consideration. Assessments need
to explore all facets of individuals, and care plans need to reflect their
unique needs. Being more inclusive of LGBTQ individuals, or being an
advocate on committees in the workplace, can also be a beneficial step in
improving the care of older LGBTQ adults.
In their position of advocacy for vulnerable older persons,
gerontological nurses can impact the care of, and engender trust in, LGBTQ
older adults, while serving as an example that could improve the care other
health care workers provide.
PRACTICE REALITIES
You are a nurse manager in an assisted living community that serves an
affluent population. The current resident population is all White, whereas
most of the caregiving staff is African American.
Some of the staff shared with the nurse manager their frustration at the
way several residents treat them. Although most of the residents are
courteous and polite in their manner of speaking to staff, some have a
tendency to use terms like “girls,” “you people,” and “the help.” In
addition, staff complain that visitors often ask them to do things that really
are not part of their jobs, such as having them go to visitors’ cars to retrieve
something or serve food that visitors bring in for themselves and their
family.
The African American staff believe that they are being treated in a
prejudicial manner. One nursing assistant comments, “You would think this
was their plantation, and we were their slaves.” Another reacts, “Yes, but if
we dare to say something to them, they’ll be running to administration. I
can’t afford to lose this job.” Yet another adds, “Maybe we should live with
it. White people have always been this way to our people.”
As the nurse manager, how would you handle this situation?

1. What are some reasons for older adults of minority groups to be
suspicious or distrustful of health care services in this country?
2. What would you do if faced with a situation in which an older client
refused to allow you to provide nursing care for him or her because
you are of a different ethnic or racial group?
3. You are working in a hospital that serves a large population of
immigrants who have not entered the country legally. These
individuals frequently have had poor health care and present with
multiple chronic conditions. The hospital is concerned that the care
offered to these immigrants is placing a significant strain on its budget
and may threaten its survival. The local community does not want to
lose its hospital and has voiced opposition to providing free care for
this group of immigrants. What do you see as concerns for all parties
involved? What are the implications of either continuing or
discontinuing free care to this group of immigrants? What solutions
could you recommend?
4. A nursing home has a variety of ethnic groups represented in the
resident population. What can the facility do to show sensitivity to
their backgrounds?
Chapter Summary
The aging population is becoming more racially, ethnically, and sexually
diverse. Older Hispanics are the fastest-growing segment of the U.S.
population, and English may be a second language to them. They may view
God as having an important role in their health and healing and may utilize
traditional practitioners to treat health problems. Families may hold older
relatives in high esteem and try to avoid placing them in nursing homes.
The black population consists of Africans, Haitians, Jamaicans, and
other diverse subgroups who have unique customs and beliefs. Although the
black population has a lower life expectancy, black individuals who reach
their seventh decade of life have the same potential life expectancy as the
white population. Hypertension, heart disease, cancer, and diabetes are
leading causes of death among older black persons.
Individuals from China, Japan, the Philippines, Korea, Vietnam, and
Cambodia are among the population of Asian Americans. Some of these
individuals may prefer traditional medicine to conventional Western
medicine. Families may play an important role in the lives of older Asian
Americans.
Jewish Americans are bound by a common faith. Sabbath is from
sundown Friday to sundown Saturday; medical procedures may be opposed
during this time. Adhering to a Kosher diet may be important to faithful
Jews, as may fasting on holy days. Family bonds are important.
American Indians and Alaskan Natives constitute Native Americans
and are one of the fastest-growing minorities in the United States. Less than
half of American Indians reside on reservations, and those who do have
access to free services from the U.S. Public Health Service. Diabetes,
obesity, hypertension, and rheumatoid arthritis occur more commonly
among Native American elders than in other older populations. Native
rituals and healers may be preferred to Western medicine. Families share
close relationships and hold their elders in high esteem.
Muslims share a common culture based on the belief that Allah is God
and Muhammad his messenger. Customs and rituals arise from their
religious beliefs. Older Muslims represent less than 1% of the Muslim
population and may be held in high esteem. Devout Muslims adhere to
specific dietary practices and may prefer care by a person of the same sex.
Traditional Muslim individuals who are unconscious or terminally ill
should lie so their face is positioned to look toward Mecca.
The LGBTQ population is growing. Some older LGBTQ individuals
lived during an era when their sexual preferences were not as accepted as
they are today; thus, those individuals may not readily divulge their sexual
preferences. Health care facilities are gaining in their understanding of the
needs and rights of these individuals.
Although some members of a group may exhibit similar traits, nurses
must be careful to assess individual characteristics, preferences, and
practices and avoid stereotyping. It is important for nurses to respect
individual differences and assess for and incorporate personal preferences
and practices into care.
Online Resources
Bureau of Indian Affairs
http://www.bia.gov
Center of Excellence for Transgender Health
http://transhealth.ucsf.edu#sthash.8g2c7ai7.dpuf
National Asian Pacific Center on Aging
http://www.napca.org
National Association for Hispanic Elderly
http://www.anppm.org
National Caucus & Center on Black Aged
http://www.ncba-aged.org
National Hispanic Council on Aging
http://www.nhcoa.org
National Indian Council on Aging
http://www.nicoa.org
National Resource Center on LGBT Aging
http://www.lgbtagingcenter.org
National Resource Center on Native American Aging
http://www.med.und.nodak.edu/depts/rural/nrcnaa/
Office of Minority Health Resource Center
http://www.minorityhealth.hhs.gov
Organization of Chinese Americans
http://www.ocanational.org
SAGE (Advocacy and Services for LGBT Elders)
http://sageusa.org/index.cfm
References
Administration on Aging. (2018). 2018 Profile of older Americans. Retrieved January 15, 2020 from
https://acl.gov/sites/default/files/Aging%20and%20Disability%20in%20America/2018OlderAm
ericansProfile.pdf
Advocacy and Services for LGBT Elders (SAGE). (2019). The facts on LGBT aging. Retrieved
January 12, 2020 from https://www.sageusa.org/wp-content/uploads/2018/05/sageusa-the-facts-
on-lgbt-aging.pdf
American Lung Association. (2019). Tobacco use in racial and ethnic populations. Smoking Facts.
Retrieved March 13, 2020 from https://www.lung.org/stop-smoking/smoking-facts/tobacco-use-
racial-and-ethnic.html
Caceres, B. A., Travers, J., Primiano, J. E., Luscombe, R. E., & Dorsen, C. (2019). Provider and
LGBT individuals’ perspectives on LGBT issues in long-term care: A systematic review. The
Gerontologist, 60 (3), e169–e183. doi: 10.1093/geront/gnz012.
Centers for Disease Control and Prevention. (2017). Health of black or African American non-
Hispanic population. FastStats. Retrieved March 13, 2020 from
http://www.cdc.gov/nchs/fastats/black-health.htm
Centers for Disease Control and Prevention. (2018). Adult obesity facts. Retrieved January 5, 2020
from https://www.cdc.gov/obesity/data/adult.html
Centers for Disease Control and Prevention. (2019). Current cigarette smoking among adults aged 18
and over, by selected characteristics: United States, average annual, selected years 1990–1992
through 2015–2017. Retrieved January 5, 2020 from
https://www.cdc.gov/nchs/hus/contents2018.htm#Table_019
Indian Health Services. (2019). Disparities. Retrieved March 14, 2020 from
https://www.ihs.gov/newsroom/factsheets/disparities/
Jewish Virtual Library. (2020). Vital statistics: Jewish population of the world (1882-present).
Retrieved March 13, 2020 from https://www.jewishvirtuallibrary.org/jewish-population-of-the-
world
Kaiser Family Foundation. (2019). Key facts on health and health care by race and ethnicity.
Retrieved March 13, 2020 from https://www.kff.org/disparities-policy/report/key-facts-on-
health-and-health-care-by-race-and-ethnicity/
Kim, H. J., Fredriksen-Goldsen, K. I., Bryan, A. E., & Muraco, A. (2017). Social network types and
mental health among LGBT older adults. Gerontologist, 57 (2 Supplement), S84–S94. doi:
10.1093/geront/gnw169.
Le, C. N. (2020). 14 Important statistics about Asian-Americans. Asian-Nation: The Landscape of
Asian Americans. Retrieved March 13, 2020 from http://www.asian-nation.org/14-
statistics.shtml
Ledford, H. (2019). Millions of black people affected by racial bias in health-care algorithms. Nature,
574 (7780), 608–609.
National Cancer Institute. (2019). Cancer disparities. Retrieved January 7, 2020 from
https://www.cancer.gov/about-cancer/understanding/disparities
National Indian Council on Aging. (2019). Diabetes still highest among American Indians and
Alaska Natives. Retrieved January 7, 2020 from https://www.nicoa.org/diabetes-still-highest-
among-ai-an/
Passell, J. S., & Chon, D. (2019). Mexicans decline to less than half the U.S. unauthorized immigrant
population for the first time. Pew research Center. Retrieved January 21, 2020 from
https://www.pewresearch.org/fact-tank/2019/06/12/us-unauthorized-immigrant-population-
2017/
Pew Research Center. (2019). College graduates who are Jewish. Retrieved January 5, 2020 from
https://www.pewforum.org/religious-landscape-study/religious-tradition/jewish/educational-
distribution/college/
Population Reference Bureau. (2019). Fact sheet: Aging in the United States. Retrieved January 10,
2020 from https://www.prb.org/aging-unitedstates-fact-sheet/
U.S. Bureau of Labor Statistics. (2020). Labor force statistics from the current population survey.
Retrieved March 13, 2020 from https://www.bls.gov/web/empsit/cpsee_e16.htm
U.S. Census Bureau. (2018). Language spoken at home. Retrieved January 10, 2020 from
https://data.census.gov/cedsci/table?
q=language&g=&hidePreview=false&table=S1601&tid=ACSST1Y2018.S1601&lastDisplayed
Row=25&vintage=2018
U.S. Department of Health and Human Services Office of Minority Health. (2018). Profile:
American Indian/Alaska Native. Retrieved January 6, 2020 from
https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=62
U.S. Department of Health and Human Services Office of Minority Health. (2019a). Profile:
Black/African Americans. Retrieved March 13, 2020 from
https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=61
U.S. Department of Health and Human Services Office of Minority Health. (2019b). Profile:
Hispanic/Latino Americans. Retrieved January 5, 2020 from
https://www.minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=64
Yano, Y., Tanner, R. M., Sakhuja, S., Jaeger, B. C., Booth, J. N., et al. (2019). Association of daytime
and nighttime blood pressure with cardiovascular disease events among African American
individuals. JAMA Cardiology, 4 (9), 910–917.
CHAPTER 4
Life Transitions and Story
CHAPTER OUTLINE
Ageism
Changes in Family Roles and Relationships
Parenting
Grandparenting
Loss of Spouse
Retirement
Reduced Income
Changes in Health and Functioning
Cumulative Effects of Life Transitions
Responding to Life Transitions
Self-Reflection
LEARNING OBJECTIVES
1. Discuss ageism and its consequences.

2. Discuss changes that occur in aging families.
3. Describe challenges faced by widows.
4. Outline the phases and challenges of retirement.
5. Discuss the impact of age-related changes in health and functioning on
roles.
6. Describe cumulative effects of life transitions.
7. List nursing measures to assist individuals in adjusting to the
challenges and changes of aging.
TERMS TO KNOW
Ageismstereotyping, discriminating against, or applying prejudices to
older adults due to their age
Inner resourcesstrength within the person that can be drawn upon when
needed
Life reviewa process of reminiscing or reflecting on one’s life
Retirementthe period in which one no longer is employed
Growing old is not easy. Various changes during the aging process demand
multiple adjustments that require stamina, ability, and flexibility.
Frequently, more simultaneous changes are experienced in old age than
during any other period of life. Many young adults find it exhausting to
keep pace with technological advances, societal changes, cost-of-living
fluctuations, and labor market trends. Imagine how complex and
complicated life can be for older individuals, who must also face
retirement , reduced income, possible housing changes, frequent losses
through deaths of significant persons, and a declining ability to function.
Further, each of these life events can be accompanied by role changes that
can influence behavior, attitudes, status, and psychological integrity. To
promote awareness and appreciation of the complex and arduous
adjustments involved in aging, this chapter considers some of the factors
that affect older adults’ ability to cope with multiple changes associated
with aging and their achievement of satisfaction and well-being during the
later years.
AGEISM
Ageism , a concept introduced more than a half century ago, is defined as
“the prejudices and stereotypes that are applied to older people sheerly on
the basis of their age …” (Butler, 1969; Butler, Lewis, & Sutherland, 1998).
It is not difficult to detect overt ageism in our society. Rather than showing
appreciation for the vast contributions of older adults and their wealth of
resources, society is beset with prejudices and lacks adequate provisions for
them, thus derogating their dignity. The same members of society who
object to providing sufficient income and health care benefits for the older
population enjoy an affluence and standard of living that was the result of
the efforts of these older persons.
Although older adults constitute the most diverse and individualized
age group in the population, they continue to be stereotyped by the
following misconceptions:
Old people are sick and disabled.

Most old people are in nursing homes.
Dementia comes with old age.
People are either very tranquil or very cranky as they age.
Old people have lower intelligence and are resistant to change.
Old people are not able to have sexual intercourse and are not
interested in sex.
There are few satisfactions in old age.
For most older persons, the above statements are not true. Increased
efforts are necessary to heighten societal awareness of the realities of aging.
Groups such as the Gray Panthers have done an outstanding job of
informing the public about the facts regarding aging and the problems and
rights of older adults. More advocates for older persons are needed.
COMMUNICATION TIP
Upon first contact with an older adult, assume that interactions should
be no different than with adults of other ages unless information
gleaned from the history reveals problems that could alter
communication (e.g., dementia, impaired hearing). Address the person
with an honorific (Mr., Mrs., etc.) and then his or her last name.
Refrain from speaking as though addressing a child or using terms
such as “sweetie” and “dear.” Avoid medical jargon, and periodically
ask if the person understands what is being said.
Ageism carries several consequences. By separating people of

advanced age from themselves, younger people are less likely to see the
similarities between themselves and older adults. This not only leads to a
lack of understanding of older people but also reduces the opportunities for
the young to gain realistic insights into aging. Furthermore, separating older
individuals from the rest of society makes it easier for younger individuals
to minimize the socioeconomic challenges of the older population.
However, systematically stereotyping and discriminating against older
persons will not prevent individuals from growing old themselves and
experiencing the challenges of old age.
Chapter 2 outlines Erikson’s (1993) stages of life in which he describes
the last stage of the life cycle as concerned with achieving integrity versus
despair. Integrity results when the older individual derives satisfaction from
an evaluation of his or her life. Disappointment with life and the lack of
opportunities to alter the past bring despair. Ageism, unfortunately, can
predispose aging persons to disappointment because they may believe
stereotypical views that old age is a time of purposelessness and decline.
The experiences of our entire lifetime determine whether our old age will
be an opportunity for freedom, growth, and contentment or a miserable
imprisonment of our human potential.
CHANGES IN FAMILY ROLES AND

RELATIONSHIPS
The emergence of today’s nuclear family units changed the roles and
functions of the individu als in a family. Older parents are expected to have
limited input into the lives of their adult children. Children are not required
to meet the needs of their aging parents for financial support, health
services, or housing. Parents increasingly do not depend on their children
for their needs, and the belief that children are the best insurance for old age
is fading. In addition, grandparenting, although satisfying, is not usually as
active a role as in the past, especially because grandchildren may be
scattered throughout the country. These changes in family structure and
function are not necessarily negative. Older adults may enjoy the
independence and freedom from responsibilities that nuclear family life
offers. Adjusting to changes in responsibilities and roles over time, though,
is an important challenge of aging.
Parenting
The dynamic parental role frequently changes to meet the growth and
development needs of both parent and child. During middle and later life,
parents must adjust to the independence of their children as they become
responsible adult citizens and leave home. The first child usually leaves
home and establishes an independent unit 22 to 25 years after the parents
married. For persons who have invested most of their adult lives nurturing
and providing for their offspring, a child’s independence may have
significant impact. Although parents who are freed from the responsibilities
and worries of rearing children have more time to pursue their own
interests, they are also freed from the meaningful, purposeful, and satisfying
activities associated with child rearing, and this frequently results in a
profound sense of loss.
Women who are part of the Silent Generation, born from 1925 to 1945,
and those who are part of the early baby boomer generation, born between
1946 and 1964, have been influenced by a historical period that emphasized
the role of wife and mother. For instance, to provide job opportunities for
men returning from World War II, women were encouraged to focus their
interests on raising a family and to forfeit the scarce jobs to men. Unlike
many of today’s younger women, who pursue and may equally value both a
career and motherhood, these older women centered their lives on their
families, from which they derived their sense of fulfillment. Having
developed few roles from which to achieve satisfaction other than those of
wife and mother, many of these older women feel a void when their
children are grown and gone. Compounding this problem, the highly mobile
lifestyle of many young persons limits the degree of direct contact an older
woman has with her adult children and grandchildren.
The older man shares many of the same feelings as his wife.
Throughout the years, he may have felt that he has performed useful
functions that made him a valuable member of the family. Most likely, he
worked hard to support his wife and children, and his masculinity was
reinforced with proof of his ability to beget and provide for offspring. Now,
with his children grown, he is no longer required to provide—a mixed
blessing in which he may find both relief and purposelessness. In addition,
he learns that the rules have changed—his ability to support a family
without the need for his wife to work is now viewed by some as oppressive,
his efforts to replenish the earth are scorned by zero population proponents,
and his attempt to fill the masculine role for which he was socialized is
considered oppressive or inane by today’s standards.
However, this lessening of the parenting role and the changes in family
function are not necessarily negative. Most children do not abandon or
neglect their aging parents; they maintain regular contact. Separate family
units may help the parent–child relationship develop on a more adult-to-
adult basis, to the mutual satisfaction of both the young and the old. If older
adults adjust to their new role as parents of independent, adult children,
they may enjoy the freedom from previous responsibilities and the new
developments in their family relationships.
POINT TO PONDER
List at least three ways that your life is different from the lives of your
parents and grandparents.
Grandparenting
In addition to experiencing changes in the parenting role that come with
age, many older adults enter a new role as grandparents. Americans’
extended life expectancy enables more people to experience the role of
grandparent and spend more years in that role than previous generations.
More than 70 million Americans are grandparents, and:
Most are baby boomers, and nearly one third are college educated.
Four in ten grandparents today are in the workforce.
One in three grandparents is foreign born, and two in five have a
grandchild of a different race or ethnicity.
They are spending more on grandchildren than previous generations
(AARP, 2019).
Grandchildren can bring considerable joy and meaning to the lives of

older adults (Fig. 4-1). In turn, grandparents who are not burdened with the
same daily child-rearing responsibilities of parents can offer love, guidance,
and enjoyment to the family’s young. They can share lessons learned from
their life experiences and family history and traditions that help the young
understand their roots. There can be as many grandparenting styles as there
are personalities; there is no single model of grandparenthood.
Figure 4-1 Grandparenting offers new roles and joys for
many older adults.
Changes in the family structure and activities present new challenges to

today’s grandparents. Most mothers are employed outside of the home. This
is compounded by the fact that approximately one third of children are
being raised by one parent. As a result, grandparents may assume childcare
responsibilities to a greater extent than previous generations did.
Grandparents may even provide for or share a home with their children and
grandchildren. Family structures may differ from older adults’ experience,
with an increase in remarriage and blended families as well as homosexual
households. More than one third of children under 18 years live in blended
households, and it is estimated that as many as 4 million children have gay
or lesbian parents (Family Equality Council, 2019). As a result of an adult
child’s marriage or relationship, older adults may find themselves becoming
step-grandparents, a role for which few are prepared. Conscious choices
will be needed to love and accept these new family members.
In addition to older adults having to adapt to new family lifestyles and
structures, children and grandchildren may need to adapt to grandparents
who have different lifestyles from previous generations. Rather than the
stay-at-home grandma who cooked elaborate family dinners and welcomed
grandchildren whenever they needed a sitter, today’s grandmother may have
an active career and social calendar and not want to be burdened with
frequent babysitting responsibilities or hosting family functions.
Grandparents may be divorced, causing their children and grandchildren to
face issues such as grandmother’s weekend trips with her new male friend
or grandpop’s new, much younger wife. The family may need to be referred
for counseling to help them address these issues.
Grandparenthood is a learned role, and some older individuals may
need guidance to become effective grandparents. Older adults may need to
be guided in thinking through issues such as:
Respecting their children as parents and not interfering in the parent–

child relationship
Calling before visiting
Establishing rules for babysitting
Allowing their children to establish their own traditions within their
family and not expecting them to adhere to the grandparent’s traditions
Nurses can help families locate resources that can assist in meeting the
challenges of grandparenting. Also, nurses can suggest activities that can
help grandparents be connected with their grandchildren, particularly if they
are not geographically close; these can include audio- and videotapes, e-
mails, videoconferencing, texting, Facebook posts, faxes, and handwritten
letters. (In addition to offering a means of communication, these can
provide lasting memories that can be passed from one generation to the
next.) Older adults can be encouraged to keep diaries, scrapbooks, and
notebooks of family recipes and customs that can help their grandchildren
and future generations have special insights into their ancestors.
In addition to fulfilling the grandparenting role, many older adults may
assume primary child-rearing responsibilities for their grandchildren. An
increasing number of grandparents are raising grandchildren. Nearly 2
million grandparents have grandchildren under the age of 18 living with
them, and many more live with their grandparents off and on; a grandparent
is providing care for nearly one fourth of children younger than 5 years
(U.S. Census Bureau, 2018). Full-time caregiving often arises out of crises
with the child’s parents, such as substance abuse, teen pregnancy, or
incarceration. Older persons may need help thinking through the
implications of deciding to raise a grandchild; some questions that nurses
can raise with grandparents contemplating this decision include the
following:
How will raising this child affect your own health, marriage, and
lifestyle?
Do you have any health conditions that could interfere with this
responsibility?
What is your backup plan in the event that you become ill or disabled?
Do you have the energy and physical health required to care for an
active child?
Can you afford to care for the child, pay medical and educational
expenses, and the like?
What rights and responsibilities will the child’s parent(s) have?
Do you have the legal right to serve as a surrogate parent (e.g., to give
consent for medical procedures)? Have you consulted with an
attorney?
Organizations exist to assist grandparents who are raising

grandchildren; some are listed at the end of this chapter.
LOSS OF SPOUSE
The death of a spouse is a common event that alters family life for many
older persons. The loss of that individual with whom one has shared more
love and life experiences and more joys and sorrows than anyone else may
be intolerable. How, after many decades of living with another person, does
one adjust to his or her sudden absence? How does one adjust to setting the
table for one, to coming home to an empty house, or to not touching that
warm, familiar body in bed? Adjustment to this significant loss is coupled
with the demand to learn the new task of living alone (Fig. 4-2).
Figure 4-2 For an older adult, the loss of a spouse means
the loss of one’s closest companion of many years.
The death of a spouse affects more women than men because women
tend to have a longer life expectancy than men. In fact, most women will be
widowed by the time they reach their eighth decade of life. Unlike many of
today’s younger women, who have greater independence through careers
and changed norms, most of today’s older women have led family-oriented
lives and have been dependent on their husbands. Their age, limited
education, lack of skills, and long period of unemployment while raising
their families are limitations in a competitive job market. If these women
can find employment, adjusting to the new demands of work may be
difficult and stressful. The unemployed widow, however, may learn that
pensions or other sources of income may be reduced or discontinued when
the husband dies, necessitating an adjustment to an extremely limited
budget. In addition to financial dependence, the woman may have depended
on her husband’s achievements to provide her with gratification and
identity. Frequently, the achievements of children serve this same purpose.
Sexual desires may be unfulfilled because of lack of opportunity, religious
beliefs regarding sex outside marriage, fear of repercussion from children
and society, or residual attitudes from early teachings about sexual mores. If
a woman’s marriage promoted friendships with other married couples and
only inactive relationships with single friends, the new widow may find that
her number of single female friends is small.
For the most part, when the initial grief of the husband’s death passes,
most widows adjust quite well. The high proportion of older women who
are widowed provides an availability of friends who share similar problems
and lifestyles, especially in urban areas. Old friendships may be revived to
provide sources of activity and enjoyment. Some widows may discover that
the loss of certain responsibilities, such as cooking and laundering for their
husbands, brings them a new, pleasant freedom. With alternative roles to
develop, sufficient income, and choice over lifestyle, many women are able
to make a successful adjustment to widowhood.
The likelihood of an older adult remarrying after the loss of a spouse
diminishes with age. This is especially true for women who often live
longer than men and find a shortage of eligible men, because men of the
same age tend to marry women younger than themselves.
Nurses may facilitate the adjustment to widowhood by identifying
sources of friendships and activities such as clubs, volunteer organizations,
or groups of widows in the community and by helping the widow
understand and obtain all the benefits to which she is entitled. This may
require reassuring the widow that enjoying her new freedom and desiring
relationships with other men is no reason to feel guilty and may help her to
adjust to the loss of her husband and the new role of widow. (See Chapter
36 for more information on death and dying.)
KEY CONCEPT
The high prevalence of widows provides opportunities for friendships
between women who share similar challenges and lifestyles.
RETIREMENT
Retirement is another of the major adjustments of an aging individual. This
transition brings the loss of a work role and is often an individual’s first
experience of the impact of aging. In addition, retirement can require
adjusting to a reduced income and consequent changes in lifestyle.

Retirement is especially difficult in Western society, in which worth is
commonly measured by an individual’s productivity. Work is also often
viewed as the dues required for active membership in a productive society.
Many of today’s older persons, raised to value a strong work ethic, hold the
attitude that unemployment, for whatever reason, is an undesirable state.
KEY CONCEPT
Older adults often view work as the dues required for active membership
in a productive society.
Occupational identity largely determines an individual’s social position
and social role. Although individuals function differently in similar roles,
some behaviors continue to be associated with certain roles, which promote
stereotypes. Certain stereotypes continue to be heard frequently—the tough
construction worker, the wild exotic dancer, the fair judge, the righteous
clergyman, the learned lawyer, and the eccentric artist. The realization that
these associations are not consistently valid does not prevent their
propagation. Too frequently, individuals are described in terms of their
work role rather than their personal characteristics, for example, “the nurse
who lives down the road” or “my son the doctor.” Considering the extent to
which social identity and behavioral expectations are derived from the work
role, it is not surprising that retirement threatens an individual’s sense of
identity (Fig. 4-3). During childhood and adolescence, we are guided
toward an independent, responsible adult role, and in academic settings, we
are prepared for our professional roles, but where and when are we prepared
for the role of retiree?
Figure 4-3 People who define self by their work role may
have difficulty adjusting to retirement.
POINT TO PONDER
What do you derive, or think you will derive, from being a nurse in
terms of purpose, identity, values, relationships, activities, and so on?
What similar gains are you achieving from other roles in your life?
When one’s work is one’s primary interest, activity, and source of social
contacts, separation from work leaves a significant void in one’s life. Aging
individuals should be urged to develop interests unrelated to work.
Retirement is facilitated by learning how to use, appreciate, and gain
satisfaction from leisure time throughout an employed lifetime. In addition,
enjoying leisure time is a therapeutic outlet for life stresses throughout the
aging process.
KEY CONCEPT
When work is one’s primary interest, activity, and source of social
contacts, separation from work leaves a significant void in one’s life.
Gerontological nurses must understand the realities and reactions

encountered when working with retired persons. Although the experience of
retirement is unique for each individual, some reactions and experiences
tend to be fairly common. The phases of retirement described by Robert
Atchley decades ago continue to offer insight into this complicated process:
Preretirement phase. When the reality of retirement is evident,

preparation for leaving one’s job begins, as does fantasy regarding the
retirement role.
Retirement phase. Following the retirement event, a somewhat
euphoric period begins, a “honeymoon period,” in which fantasies
from the preretirement phase are tested. Retirees attempt to do
everything they never had time for simultaneously. A variety of factors
(e.g., finances and health) limit this, leading to the development of a
stable lifestyle. As contrasted with those retirees who want to engage
in every fantasy, some individuals choose to rest and do very little;
their activity level tends to increase after a few years.
Disenchantment phase. As life begins to stabilize, a letdown,
sometimes a depression, is experienced. The more unrealistic the
preretirement fantasy, the greater the degree of disenchantment.
Reorientation phase. As realistic choices and alternative sources of
satisfaction are considered, the disenchantment with the new
retirement routine can be replaced by developing a lifestyle that
provides some satisfaction.
Retirement routine phase. An understanding of the retirement role is
achieved, and this provides a framework for concern, involvement, and
action in the older person’s life. Some enter this phase directly after the
honeymoon phase, and some never reach it at all.
Termination of retirement. The retirement role is lost as a result of
either the resumption of a work role or dependency due to illness or
disability (Atchley, 1975, 2003).
Different nursing interventions may be required during each phase of

retirement. Assisting aging individuals with their retirement preparations
during the preretirement phase is a preventive intervention that enhances
the potential for health and well-being in late life. As a part of such
intervention, nurses can encourage aging individuals to establish and
practice good health habits such as following a proper diet; avoiding
alcohol, drug, and tobacco use; and having regular physical examinations.
Counseling regarding the realities of retirement may be part of retirement
preparation, whereas helping retirees place their newfound freedom into
proper perspective may be warranted during the honeymoon period of the
retirement phase. Being supportive of retirees during the disenchantment
phase without fostering self-pity and helping them identify new sources of
satisfaction may facilitate the reorientation process. Appreciating and
promoting the strengths of the stability phase may reinforce an adjustment
to retirement. When the retirement phase is terminated due to disease or
disability, the tactful management of dependency and the respectful
appreciation of losses are extremely important.
As they have done with other life events, baby boomers are changing
the thinking about work and retirement. Increasingly, they are replacing the
model of a person being defined by his or her work with one that defines a
person’s work based on the totality of his or her life. Life coaches and
retirement planners are guiding baby boomers to learn prior to retirement to
seek fulfillment by engaging in family, leisure, learning, and service
activities that they may have been postponing. Rather than forfeit working
altogether during retirement, people could consider staying in the
workforce, but in a different style—that is, one that leaves time for the
enjoyment of other interests and a high quality of life. The baby boomers
also are remaining in the workforce longer, with many finding new paths of
employment that enable them to explore their passions and achieve a
different sense of purpose, even if it is at lower levels of compensation.
Nurses’ evaluations of their own attitudes toward retirement are
beneficial. Does the nurse see retirement as a period of freedom,
opportunity, and growth or as one of loneliness, dependency, and
meaninglessness? Is the nurse intelligently planning for his or her own
retirement or denying it by avoiding encounters with retirement realities?
Nurses’ views of retirement affect the retiree–nurse relationship.
Gerontological nurses can provide especially good models of constructive
retirement practices and attitudes.
Reduced Income
In addition to the adjustment in work role, retirement often requires older
adults to live on a reduced income. Financial resources are important at any
age because they affect our diet, health, housing, safety, and independence
and influence many of our choices in life. Retirement income is less than
half the income earned while fully employed. For most older Americans,
Social Security income, originally intended as a supplement, is actually the
primary source of retirement income—and it has not kept pace with
inflation. As a result, the economic profile of many older persons is poor.
Only a minority of the older population has income from a private
pension plan, and those who do often discover that the fixed benefits
established when the plan was subscribed are meager by today’s standards
because of inflation. Of the workers who are currently active in the labor
force, more than half will not have pension plans when they retire. More
than 9% of all older adults live in poverty, with older African Americans
and Hispanics having nearly twice the rate of poverty as older white
persons. Only a minority are fully employed or financially comfortable.
Few older persons have accumulated enough assets during their lifetime to
provide financial security in old age.
A reduction in income is a significant adjustment for many older
persons because it triggers other adjustments. For instance, an active social
life and leisure pursuits may have to be markedly reduced or eliminated.
Relocation to less expensive housing may be necessary, possibly forcing the
aged to break many family and community ties. Dietary practices may be
severely altered, and health care may be viewed as a luxury over which
other basic expenses, such as food and rent, take priority. If the older parent
has to depend on children for supplemental income, an additional
adjustment may be necessary.
Making financial preparations for old age many years before retirement
is important. Nurses should encourage aging working people to determine
whether their retirement income plans are keeping pace with inflation. Also,
older individuals need assistance in obtaining all the benefits they are
entitled to and in learning how to manage their income wisely. Nurses
should be aware of the impact of economic welfare on health status and
should actively involve themselves in political issues that promote adequate
income for all individuals.
POINT TO PONDER
What are you doing to prepare for your own retirement?
CHANGES IN HEALTH AND
FUNCTIONING
The changes in appearance and bodily function that occur during the aging
process make it necessary for the aging individual to adjust to a new body
image. Colorful soft hair turns gray and dry, flexible straight fingers
become bent and painful, body contours are altered, and height decreases.
Stairs once climbed several times daily demand more time and energy to
negotiate as the years accumulate. As subtle, gradual, and natural as these
changes may be, they are noticeable and, consequently, affect body image
and self-concept.
The manner in which individuals perceive themselves and their
functional abilities can determine the roles they play. A construction worker
who has reduced strength and energy may forfeit his work role; a club
member who cannot hear conversations may cease attending meetings;
fashion models may stop seeking jobs when they perceive themselves as
old. Interestingly, some persons well into their seventh and eighth decades
refuse to join a senior citizen club because they do not perceive themselves
as being “like those old people.” The nurse will gain insight into the self-
concept of older persons by evaluating what roles they are willing to accept
and what roles they reject. Refer to Nursing Problem Highlight 4-1 for a
discussion of the inability to fulfill responsibilities.
It is sometimes difficult for the aging person to accept the body’s
declining efficiency. Poor memory, slow response, easy fatigue, and altered
appearance are among the many frustrating results of declining function,
and they are dealt with in various ways. Some older people deny them and
often demonstrate poor judgment in an attempt to make the same demands
on their bodies as they did when younger. Others try to resist these changes
by investing in cosmetic surgery, beauty treatments, miracle drugs, and
other expensive endeavors that diminish the budget but not the normal
aging process. Still others exaggerate these effects and impose an
unnecessarily restricted lifestyle on themselves. Societal expectations
frequently determine the adjustment individuals make to declining function.
Common results of declining function are illness and disability. As
described in Chapter 1, most older people have one or more chronic
diseases, and more than one third have a serious disability that limits major
activities such as work and housekeeping. Older adults often fear that
illness or disability may cause them to lose their independence. Becoming a
burden to their family, being unable to meet the demands of daily living,
and having to enter a nursing facility are some of the fears associated with
dependency. Children and parents may have difficulty exchanging
dependent–independent roles. The physical pain arising from an illness may
not be as intolerable as the dependency it causes.
Nurses should help aging persons understand and face the common
changes associated with advanced age. Factors that promote optimum
function should be encouraged, including proper diet, paced activity, regular
physical examination, early correction of health problems, effective stress
management, and avoidance of alcohol, tobacco, and drug abuse. Nurses
should offer assistance, with attention to preserving as much of the
individual’s independence and dignity as possible.
NURSING PROBLEM HIGHLIGHT 4-1

INABILITY TO FULFILL
RESPONSIBILITIES
Overview
A variety of factors can prevent older adults from fulfilling their
responsibilities. For some, it may be a lifelong pattern; for others, it can be
the result of physical, cognitive, emotional, or socioeconomic factors that
interfere with function. In addition to responsibilities not being fulfilled,
depression, anxiety, and threats to health and well-being can result from
this problem.
Causative or Contributing Factors
Illness, fatigue, pain, declining function, altered cognition, depression,
anxiety, knowledge deficit, limited finances, adjustment to retirement, lack
of transportation, loss of significant other, ageism, and enabling or
restrictions imposed by others
Goal
The client improves ability to fulfill responsibilities or develops a means
to have the responsibilities met via another source.
Interventions
Assess client’s responsibilities; identify the responsibilities that are
not being fulfilled, potential contributing factors, and client’s reaction
and desires.
Assist client in realistically evaluating cause of deficits in fulfilling
roles, and his or her desire and potential for improvement in role
performance.
Identify specific strategies to improve role fulfillment (e.g.,
instructing, discussing with family members the importance of
allowing client to perform role, counseling client to accept limitation
that can’t be improved, referring to community resources, improving
health problem, encouraging client to seek help with responsibilities,
and advising for stress management).
Encourage client to discuss concerns with family members; assist
client in arranging family conference.
Refer client to assistive resources, as appropriate, such as support
groups, occupational therapist, financial counselor, counseling and
employment service for people over 60 years of age, visiting nurse, or
social services.
Unfolding Patient Stories: Millie Larsen • Part 1

Millie Larsen is an 84-year-old female who
lives alone. Her husband passed away a year ago, and she now depends on
her daughter, Dina, who lives nearby. Her current medical problems
include hypertension, glaucoma, osteoarthritis of the knee, stress
incontinence, osteoporosis, and hypercholesterolemia. She takes several
medications to treat hypertension and pain. How can ageism influence the
nurse’s view of Millie’s health care needs? How can the nurse identify
Millie’s attitudes toward her own aging that might be influencing her self-
care behaviors? What options for caregiving support should the nurse be
prepared to discuss if Millie’s wellness and function decline? (Millie
Larsen’s story continues in Chapter 28.)
Care for Millie and other patients in a realistic virtual environment:
(thepoint.lww.com/vSimGerontology). Practice documenting these
patients’ care in DocuCare (thepoint.lww.com/DocuCareEHR).
CUMULATIVE EFFECTS OF LIFE

TRANSITIONS

Many of the changes associated with aging result in loss of social
connections and increasing risk of loneliness. Children are grown and gone,
friends and spouse may be deceased, and others who could allay the
loneliness may avoid the older individual because they find it difficult to
accept the changes they see or to face the fact that they too will be old
someday. Living in a sparsely populated rural area can geographically
isolate older persons, and fears of crime when living in an urban area may
prevent older adults from venturing outside their homes.
Hearing and speech deficits and language differences can also foster
loneliness. Even if in the company of others, these functional limitations
can socially isolate an older person. In addition, insecurity resulting from
multiple losses in communication abilities can lead to suspiciousness of
others and a self-imposed isolation.
At a time of many losses and adjustments, personal contact, love, extra
support, and attention—not isolation—are needed. These are essen tial
human needs. It is likely that a failure to thrive will occur in adults who feel
unwanted and unloved just as it does in infants, who display anxiety,
depression, anorexia, and behavioral and other difficulties when they
perceive love and attention to be inadequate.
Nurses should attempt to intervene when they detect isolation and
loneliness in an older person. Various programs provide telephone
reassurance or home visits as a source of daily human contact. The person’s
faith community may also provide assistance. Nurses can help the older
adult locate and join social groups and perhaps even accompany the
individual to the first meeting. A change in housing may be necessary to
provide a safe environment conducive to social interaction. If the older
person speaks a language other than English, relocation to an area in which
community members speak that language can often remedy loneliness.
Frequently, pets serve as significant and effective companions for older
adults.
Using common sense in nursing care will facilitate social activity. The
nurse can review and perhaps readjust the person’s schedule to conserve
energy and maximize opportunities for socialization. Medication
administration should be planned so that during periods of social activity
analgesics will provide relief, tranquilizers will not sedate, diuretics will not
reach their peak, and laxatives will not begin working. Likewise, fluid
intake and bathroom visits before activities begin should be planned to
reduce the fear or actual occurrence of incontinence; activities for older
adults should include frequent break periods for bathroom visits. The
control of these minor obstacles can often facilitate social interaction.
Nurses should also understand that being alone is not synonymous with
being lonely. Periods of solitude are essential at all ages and provide the
opportunity to reflect, analyze, and better understand the dynamics of one’s
life. Older individuals may want periods of solitude to reminisce and review
their lives. Some individuals, young and old, prefer and choose to be alone
and do not feel isolated or lonely in any way. For some, engagement
through social media provides stimulation and contact with others. Of
course, nurses should always be alert to hearing, vision, and other health
problems that may be the cause of social isolation.
CONSIDER THIS CASE
Mrs. Ko is a 66-year-old Korean woman

who has been widowed for 5 years. She and her late husband immigrated
to the United States 25 years ago and until his death ran a small
convenience store in an area close to where she currently lives. They
worked hard and were able to put their two sons through college. Her
health is good, and she manages her home without any problem. She has
two sons, one of which has lived in another state for the past 15 years and
the other who has just married and moved to another state. Mrs. Ko
doesn’t drive nor does she live in an area that has public transportation.
She attends a Korean church and is friends with a couple who drive her to
church and take her shopping.
The couple with whom she is friends informs Mrs. Ko that they will
be moving in with their daughter, who lives in another part of the state, so
they will not be able to continue their visits with her. They suggest that she
speak to her sons about moving in with one of them, stating that “our
children are supposed to take care of us.” Mrs. Ko agrees that this is the
tradition with which she was raised.
During her next telephone conversations with her sons, Mrs. Ko shares
the news about her friends’ upcoming relocation and mentions that this has
caused her to give some thought to her own future. Neither son volunteers
to have her live with his family. A few days later, she receives a call from
one of her sons, who says, “Mom, Ron (his brother) and I were talking and
we think it may be best if you moved. We found a retirement village not
far from where you live that will be good for you and that we are willing
to pay for. We’re coming into town next week to take you there to fill out
the paperwork.” Mrs. Ko is shocked by this because she has never thought
of living in a retirement community, but she doesn’t feel she should object
to her sons’ decision.
THINK CRITICALLY
1. What options are there for an older adult like Mrs. Ko to make
someone aware of her situation so that they can assist her in having
her preferences expressed and respected?
2. If Mrs. Ko’s sons are unable or unwilling to have her move in

with them, what options could be recommended?
3. How would you counsel a family when a parent’s traditional

views about children’s responsibility for their older parents conflict
with the children’s views?
KEY CONCEPT
Periods of solitude are essential to reflect, analyze, and better understand
the dynamics of life.
Widowhood, the death of friends, and the recognition of declining functions
heighten older persons’ awareness of the reality of their own deaths. During
their early years, individuals intellectually understand they will not live
forever, but their behaviors often deny this reality. The lack of a will and
burial plans may be indications of this denial. As the reality of mortality
becomes acute with advancing age, interest in fulfilling dreams, deepening
religious convictions, strengthening family ties, providing for the ongoing
welfare of family, and leaving a legacy are often apparent signs.
The thought of impending death may be more tolerable if people
understand that their life has had depth and meaning. Unresolved guilt,
unachieved aspirations, perceived failures, and other multitudinous aspects
of “unfinished business” may be better understood and perhaps resolved.
Although the state of old age may provide limited opportunities for
excitement and achievement, satisfaction may be gained in knowing that
there were achievements and excitements in other periods of life. The old
woman may be frail and wrinkled, but she can still delight in remembering
how she once drove young men wild. The retired old man may feel that he
is useless to society now, but he realizes his worth through the memory of
wars he fought to protect his country and the pride he feels in knowing he
enabled his children to obtain an education and start in life that his parents
were unable to provide him. Nurses can help older adults gain this
perspective on their lives through some of the interventions discussed in the
following sections.
RESPONDING TO LIFE TRANSITIONS

When faced with ageism and numerous changes affecting relationships,
roles, and health, older adults may respond in a variety of ways. The older
adult’s ability to cope and adjust to life changes determines whether they
reach a stage of integrity or fall to despair. Nurses can help older adults
respond to life transitions by facilitating life review and eliciting a life
story, promoting self-reflection, and strengthening older adults’ inner
resources .

Life review is the process of intentionally reflecting on past experiences in
an effort to resolve troublesome or traumatic life events and assess one’s
life in totality. The significance of a life review in interpreting and refining
our past experiences as they relate to our self-concept and help us
understand and accept our life history has been well discussed (Butler &
Lewis, 1998; Gibson, 2018). In gerontological care, life review has long
been recognized as an important process to facilitate integrity in old age
(i.e., to help older people appreciate that their lives have had meaning).
Rather than being a pathologic behavior, discussing the past is
therapeutic and important for older individuals (Fig. 4-4). Life review can
be a positive experience because older adults can reflect on the obstacles
they have overcome and accomplishments they have made. It can provide
the incentive to heal fractured relationships and complete unfinished
business. Life review, however, can be a painful experience for older adults
who realize the mistakes they’ve made and the lives they’ve hurt. Rather
than conceal and avoid these negative feelings, older adults can benefit by
discussing them openly and working through them; referrals to therapists
and counselors may be indicated to assist with unresolved grief, depression,
or anxiety.
Figure 4-4 Reminiscing is a culturally universal
phenomenon of aging. It is a way for the older adult to
reassess life experiences and further develop a sense of
accomplishment, fulfillment, and reward in life.
The young can also benefit from the reminiscences of older adults by
gaining a new perspective on life as they learn about their ancestry. Imagine
the impact of hearing about slavery, immigration, epidemics,
industrialization, or wars from an older relative who has been part of that
history. What history book’s description of the Great Depression can
compare with hearing a grandparent describe events one’s own family
experienced, such as going to bed hungry at night? In addition to their place
in the future, the young can fully realize their link with the past when the
desire of older people to reminisce is appreciated and fostered.
The nurse can facilitate life review by eliciting the older adult’s life
story. Rich threads of life experience that create the unique fabric of one’s
life are accumulated with aging. When seen in isolation, some of these
threads may seem to have little value or make little sense, much like a
network of threads on the undersurface of a tapestry. However, when the
threads are woven together and the tapestry can be viewed as a whole, a
person can see the special purpose of individual life experiences—good and
bad. Weaving the threads of life experiences into the tapestry of a life story
can be highly beneficial to the older person and others. Successes can be
appreciated, and the value of trials and failures can be realized. Others are
able to gain insight into the person’s life in totality rather than have their
understanding limited by what may be an unrepresentative segment of life
that now presents. Customs, knowledge, and wisdom can be recognized,
preserved, and passed to younger generations.
POINT TO PONDER
What are the major threads that have woven your life tapestry thus far?
Eliciting life stories from older persons is not a difficult process; in fact,
many older adults welcome opportunities to share their life histories and life
lessons to interested listeners. Nurses can encourage older adults to discuss
and analyze the dynamics of their lives, and they can be receptive and
accepting listeners. Box 4-1 outlines some of the variety of approaches
nurses can use to elicit life stories.
BOX 4-1 Eliciting Life Stories

Older adults possess rich life histories that have accrued during the many
years they have lived. These unique histories contribute to each person’s
identity and individuality. Learning about life histories aids nurses in
understanding older adults’ preferences and activities, facilitating self-
actualization, and preserving identity and continuity of life experiences.
Knowledge of life histories also enables caregivers to see their patients
in a larger context, connected to a past full of varied roles and
experiences.
A basic requisite to eliciting life stories is a willingness to listen.
Often, a direct request will be sufficient to open the door to a life history.
Activities to facilitate this process include the following:
Tree of Life. Ask the older adult to write significant events

(graduation, first job, relocations, marriages, deaths, childbirths,
etc.) from the past on each branch and then discuss each.
Timeline. Ask the older person to write significant events on or near
the year when they occurred and then discuss each.
Life Map. Ask the older adult to write significant events on the map
and discuss each.
Oral History. Ask the older adult to start with his or her earliest
memory and record the story of his or her life into a tape recorder.
(Suggest that the older person make this recording as a gift for
younger family members.) If the person needs guidance in telling
their history, offer a written outline or questions, or have a volunteer
function as an interviewer.
For older adults who may require some facilitation, creative activities,
such as compiling a scrapbook or dictating a family history, can stimulate
the process. These creative efforts, as unsophisticated as they may be,
should be recognized as significant legacies from the old to the young. For
example, one 75-year-old man started a family scrapbook for each of his
children. Any photograph, newspaper article, or announcement pertaining
to any family member was reproduced and included in every album. The
family patiently tolerated this activity and sent him copies of graduation
programs and photographs for every scrapbook. The family viewed the
main value of this activity as providing something benign to keep him
occupied. It was not until years after his death that the significance of this
great task was appreciated as a priceless gift. Such tangible items may serve
as an assurance to both young and old that the impact of an aged relative’s
life will not cease at death. Guiding older adults through this experience of
compiling a life story not only provides a therapeutic exercise for them and
an invaluable legacy for loved ones but also offers the gerontological nurse
the gift of sharing and honoring the unique life journeys of older adults.
Self-Reflection
One of the hallmarks of successful aging is knowledge of self—that is, an
awareness of the realities of who one is and one’s place in the world. From
infancy on, we engage in dynamic experiences that mold the unique
individuals we are. By adulthood, we have formed the skeleton of our
identities. Continued interactions and life experiences as we journey
through life further add to the development of our identities.
The self, the personal identity an individual possesses, has several
dimensions that basically can be described as body, mind, and spirit. The
body includes physical characteristics and functioning; the mind
encompasses cognition, perception, and emotions; and the spirit consists of
meaning and purpose derived from a relationship with God or other higher
power. A variety of factors affect the development of body, mind, and spirit,
such as genetic makeup, family composition and dynamics, roles, ethnicity,
environment, education, religious experiences, relationships, culture,
lifestyle, and health practices (Fig. 4-5).
Figure 4-5 The holistic self.
POINT TO PONDER
What are the significant factors of your background that influenced your
unique body, mind, and spirit?
Although a realistic appraisal of one’s identity and place in the world

fosters healthy aging, not all persons complete this task successfully. Some
people may live with unrealistic expectations or views of themselves, going
through life playing parts that are ill suited for them and wasting time in
fruitless or unfulfilling activities. Harry is an example of this:
Harry, the eldest of five children, was raised in an inner-city community
in which poverty was the norm. His father was an auto mechanic who had
difficulty holding jobs. His mother didn’t miss an opportunity to voice her
dissatisfaction with her husband’s meager income nor to emphasize to
Harry that he needed to be sure to “make it big and not be like his father.”
The message instilled by his mother and his desire for a better life than
he enjoyed as a child fueled Harry to be a high achiever. By age 30, Harry
owned a small chain of convenience stores, a large home in the suburbs,
several luxury cars, and most of the possessions that reflected an upper-
middle-class lifestyle. Harry was proud that he could provide a comfortable
life for his wife and expensive education for his children—quite the
opposite of what his father achieved. Yet, something was missing. His
business demanded most of his time and energy; therefore, he had little left
of himself to offer his family. He also rarely had the time for his passion,
restoring classic cars. His life seemed to consist of managing his businesses
and sleeping, with an occasional social event with his family. Time for
relaxation and reflection had no place in Harry’s busy life.
In his late 50s, with children grown and his business worth enough to
provide a comfortable retirement income, Harry was in a position where he
didn’t have to work the long days—or at all for that matter. His wife
encouraged him to consider selling his business and spend his time
“tinkering with cars and taking it easy.” Although he was tempted, Harry
felt that he just couldn’t do this. Unfortunately, the script to “make it big,”
programmed into Harry’s mind as a child, held him prisoner to a role that
brought him little joy and fulfillment. Furthermore, he had no idea of what
his purpose and identity was other than being an entrepreneur.
Like Harry, many individuals may reach their senior years without
having evaluated who they really are, what drives them to behave as they
do, or what their true purposes and pleasures are.
KEY CONCEPT
Some adults may not have invested the time and effort in self-evaluation
and, consequently, reach old age with a lack of clarity of their identity.
Exploring and learning about one’s true self are significant to holistic
health in late life. Examining and coming to terms with thoughts, feelings,
beliefs, and behaviors foster older adults’ reaching a state of integrity rather
than feeling despair over the lives they’ve lived. However, as important a
process as it is, self-reflection does not come easily or naturally for some
individuals. They may require interventions to facilitate this process;
therefore, guiding aging people through self-reflective activities is an
important therapeutic measure that gerontological nurses may need to offer.
Life review and telling one’s life story can function as self-reflective
activities. In addition, other activities that facilitate self-reflection include
journaling, writing letters and e-mails, and reflecting through art. These
certainly do not exhaust the strategies that can be used to foster self-
reflection. Nurses are bound only by their creativity in the approaches used
for promoting self-reflection.
Journaling
Whether it is done with pencil and paper or a dictation program, the process
of writing often facilitates self-reflection. There is no one right way to keep
a journal or diary; individuals should develop styles that are comfortable for
them. Some people may make daily entries that include details about their
communications, sleep patterns, mood, and activities, whereas others make
periodic entries that address major emotional and spiritual issues. Nurses
can assist individuals who have not kept journals and diaries by guiding
them in the selection of a blank book and writing instrument. This is an
important step, not only because these tools will be used often but also
because the book will be a tangible compilation of significant thoughts and
feelings that could have meaning to others in years to come. Novices to
journaling can be encouraged to start by reflecting on their lives and
beginning their journals/diaries with a summary of the past. Suggesting that
feelings and thoughts be written, in addition to the events of the day, can
contribute to the process being one that fosters self-reflection.
Writing Letters and E-Mails
Letters or e-mails are another means to reflect and express feelings. Often,
thoughts and feelings that individuals may not feel comfortable verbalizing
can be expressed in writing. For some older adults, letters of explanation
and apology to friends and family with whom there have been strained
relationships can be a healing exercise. Older people can be encouraged to
locate friends and family in other parts of the country (or world) with whom
they have not had contact for a while and to initiate communication
concerning what has transpired in their lives and current events. Letters to
grandchildren and other younger members of the family can provide a
means to share relevant family history and offer special attention (many
children love to receive their own mail!). Older adults may enjoy
communicating by e-mail because of the ease and relatively low cost. If
older adults do not own their own computers, nurses can refer them to local
senior centers or libraries that offer free or nominal-cost access to the
Internet.
Reflecting Through Art

Many people find that painting, sculpting, weaving, and other forms of
creative expression facilitate self-reflection and expression. It is important
that the process, not the finished product, be emphasized. Arts and crafts
classes and groups often are offered by local organizations dedicated to
specific activities (e.g., weavers’ guild and arts’ council), schools, and
senior centers. Nurses can assist older adults in locating such groups in their
communities.
KEY CONCEPT
Producing a work of art, discussing literature, and sharing one’s life
story are among the many interventions that can be used to foster self-
reflection.

The declines and dependencies that increasingly are present in late life can
cause us to view older adults as being fragile and incapable. However, most
older individuals possess significant inner resources—physical, emotional,
and spiritual—that have enabled them to survive to old age. Behaviors that
exemplify their survivor competencies are described in Box 4-2.
BOX 4-2 Characteristics Reflective of Survivor

Competencies of Aging Individuals
Assumption of responsibility for self-care
Mobilization of internal and external resources to solve problems
and manage crises
Development of support system via a network of family, friends,
and professional individuals and groups (e.g., social clubs,
churches, physicians, and volunteers)
Sense of control over life events
Adaptation to change
Perseverance in the face of obstacles and difficulties
Recovery from trauma
Realization and acceptance of reality that life includes positive and
negative events
Discovery of meaning in life events
Determination to fulfill personal, family, community, and work
expectations despite difficulties and distractions
Recognition of limitations and competencies
Ability to trust, love, and forgive and to accept trust, love, and
forgiveness
KEY CONCEPT
By considering the strengths displayed by older adults as they navigate
the aging process, nurses and others can develop an enlightened
perspective of the older population.
Against the backdrop of threats to independence and self-esteem, nurses
best serve older adults by maintaining and bolstering their inner strengths.
Basic to this effort is ensuring physical health and well-being. It is quite
challenging for persons of any age to optimally meet intellectual,
emotional, socioeconomic, and spiritual challenges when their basic
physical needs are not fully satisfied or they are experiencing the symptoms
associated with deviations from health. Comprehensive and regular
assessment of health status and interventions to promote health provide a
solid base from which inner strengths can be nurtured.
POINT TO PONDER
How would you judge your “survivor competencies”? What experiences
have contributed to them?
By being empowerment facilitators, nurses can support older adults’

inner strengths. Nurses must begin this process by examining and
strengthening their own level of empowerment. When nurses develop a
mindset of seeing possibilities despite fiscal and other constraints, they are
better able to help older adults see possibilities despite potential constraints
imposed by age and illness. In addition to being role models, nurses can
facilitate empowerment by:
Including and encouraging the active participation of older adults in

care planning and caregiving activities to the maximum extent possible
Avoiding ageist attitudes that can be communicated through the
manner of speaking to older adults (e.g., raising voice due to
assumption all older people are hearing impaired and using terms like
“Sweetie” or “Pops”) and practices (e.g., having signs like “Fall Risk”
or “Toilet q2h” in view of others and labeling clothing in a manner that
is visible to others)
Providing a variety of options to older people and freedom to choose
among them
Equipping older adults for maximum self-care and self-direction by
educating, relating, coaching, sharing, and supporting them
Advocating for older adults as they seek information, make decisions,
and execute their own selected self-care strategies
Offering feedback, positive reinforcement, encouragement, and
support

Nurses can facilitate empowerment by avoiding ageist attitudes and
practices, such as having signs like “Fall risk” taped to a client’s door, in
view of others.
A sense of hope fosters empowerment and is a thread that reinforces the

fabric of inner strengths. Hope is an expectation that a problem will be
resolved, relief will be obtained, and something desired will be obtained.
Hope enables people to see beyond the present and make sense of the
senseless. It empowers them to take action. Nurses foster hope in older
people by honoring the value of their lives despite infirmities and
limitations, assisting in establishing goals, supporting the use of coping
strategies, building on capabilities, and displaying an optimistic, caring
attitude. Spiritual beliefs and practices also provide inner strength that
enables older adults to cope with current challenges and maintain hope and
optimism for the future (see Chapter 30); nurses need to support older
individuals in their prayers, devotional readings, church attendance, and
other expressions of spirituality.

Meaning-Centered Men’s Groups: Initial Findings of an Intervention
to Enhance Resiliency and Reduce Suicide Risk in Men Facing
Retirement
Source: Heisel, M. J., Moore, S. L., Flett, G. L., Norman, R. M. G., Links, P.
S., & Eynan, R. et al. (2019). Clinical Gerontologist. Retrieved January 5,
2020 from https://doi.org/10.1080/07317115.2019.1666443
Retirement can pose challenges when it means the loss of a significant
role that offered meaning and purpose to life. One of the potential risks is
that as people struggle with this transition, they may become depressed and
consider suicide.
This study recruited men age 55 years and older in community settings
who faced the transition to retirement. The researchers assessed suicide
ideation as well as psychological risk and resiliency factors. The
participants who were concerned about the transition to retirement were
offered a 12-session existentially oriented psychological group intervention
to enhance psychological resiliency and reduce suicidal ideation. At the
conclusion of the sessions, participants demonstrated improvements in
psychological well-being, retirement satisfaction, life satisfaction, and
general health; depression, hopelessness, loneliness, and suicide ideation
were reduced. The researchers concluded that providing psychological
interventions can promote mental health and prevent suicide during a life
transition such as retirement.
This study implies that active measures to assist individuals facing a life
transition are important preventive health measures for nurses to consider.
When assessing middle-aged and older adults, nurses should inquire about
employment and plans for retirement; for persons who are retired,
adjustment to this role should be reviewed. Issues useful to examine are the
quality of activities that fill their days, life satisfaction, mood, quality and
quantity of social engagement, feelings of loneliness, and thoughts about
suicide. Persons demonstrating depression, poor adjustment to retirement,
or suicidal thoughts should be referred to mental health services. Sharing
information about senior citizens centers and other opportunities for social
engagement and activity can be beneficial, also.
PRACTICE REALITIES
Widowed 78-year-old Mrs. Knight lives in the house she was raised in and
in which she raised her own family. Her 56-year-old unemployed son lives
with her, and a daughter lives in a neighboring state.
Despite her independence, Mrs. Knight is a cause of concern for her
daughter who believes her brother is taking advantage of their mother. The
daughter has suggested to Mrs. Knight that she move in with her. Mrs.
Knight has refused, stating that her son “just couldn’t make it on his own.”
The daughter shares her concerns with the nurse practitioner who works
in the practice that manages Mrs. Knight’s care.
What would be reasonable actions for the nurse practitioner to take?

1. What examples of ageism can be found in television programs,
advertisements, and other vehicles of communication?
2. How will the life experiences of today’s 30-year-old woman affect her
ability to adapt to old age? What factors will enable her to cope more
or less as well than her grandmother’s generation of women?
3. Describe actions nurses can take to help aging individuals prepare for
retirement.
4. How can you determine if an older individual’s time alone is reflective
of needed solitude or social isolation?
5. How can the gerontological nurse elicit life stories from older adults in
the midst of caregiving demands during a busy shift?
6. In what ways will today’s young generation be in a better or worse
position than today’s older population in developing survivor
competencies?
Chapter Summary
One challenge and transition individuals face as they age is changes in
family roles and relationships. Nuclear families have reduced the daily
interaction and fulfillment of needs between older parents and their
children. Many older adults are grandparents, and increased numbers are
providing care for minor grandchildren.
The tendency for women to marry men older than themselves and to
have a longer life expectancy than men causes a greater prevalence of older
widows than widowers. Adjusting to widowhood can be a challenge for
some older women.
Retirement can be a transition viewed both positively and negatively.
The loss of one’s roles, routines, and relationships can be difficult, but the
freedom to explore other interests and shed unwanted responsibilities can
be welcomed. Different types of support can be beneficial during the
various phases of retirement.
Changes in health, function, and appearance are significant reminders
of the changes with age. Nurses can aid aging persons by guiding them in
positive health practices and measures to promote optimal function.
There are several processes that can help aging persons respond to life
transitions in a healthy manner. These include life review, self-reflections,
and strengthening inner resources. Nurses should explore the manner in
which older adults are responding to life transitions and offer support and
guidance to assist them in navigating these new challenges.
Online Resources
AARP Grandparent Information Center
http://www.aarp.org
AARP Retirement Calculator
http://www.aarp.org
Retirement USA Gov
http://www.usa.gov/retirement
References
AARP. (2019). 2018 Grandparents today national survey. Retrieved January 15, 2020 from
https://www.aarp.org/content/dam/aarp/research/surveys_statistics/life-leisure/2019/aarp-
grandparenting-study.doi.10.26419-2Fres.00289.001.pdf
Atchley, R. C. (1975). The sociology of retirement. Cambridge, MA: Schenkman.
Atchley, R. C. (2003). Social forces and aging (10th ed.). Belmont, CA: Wadsworth.
Butler, R. H., & Lewis, M. I. (1998). Aging and mental health (5th ed.). Boston, MA: Allyn &
Bacon.Butler, R. N. (1969). Age-ism: Another form of bigotry. The Gerontologist, 9 (4), 243–
246.
Butler, R. H., Lewis, M. I., & Sutherland, T. (1998). Aging and mental health (5th ed.). Austin, TX:
Pro.
Erikson, E. (1993). Childhood and society. New York, NY: Norton.
Family Equality Council. (2019). LGBTQ family fact sheet . Retrieved January 20, 2020 from
https://www2.census.gov/cac/nac/meetings/2017-11/LGBTQ-families-factsheet.pdf?
Gibson, F. (Ed.). (2018). International perspectives on reminiscence, life review and life story work.
Philadelphia, PA: Jessica Kingsley Publishers.
U.S. Census Bureau. (2018). Grandparents raising grandchildren. Retrieved January 2020 from
https://data.census.gov/cedsci/table?
q=grandparents%20raising%20grandchildren&g=&hidePreview=false&table=B10053&tid=AC
SDT1Y2018.B10053&lastDisplayedRow=10&vintage=2018&mode=
CHAPTER 5
Common Aging Changes
CHAPTER OUTLINE
Changes to the Body
Cells
Physical Appearance
Respiratory System
Urinary System
Reproductive System
Nervous System
Sensory Organs
Endocrine System
Immune System
Thermoregulation
Changes to the Mind
Personality
Memory
Intelligence
Learning
Attention Span
Nursing Implications of Age-Related Changes
LEARNING OBJECTIVES
1. List common age-related changes at the cellular level; in physical

appearance; and to the respiratory, cardiovascular, gastrointestinal,
urinary, reproductive, musculoskeletal, nervous, endocrine,
integumentary, and immune systems, the sensory organs, and
thermoregulation.
2. Describe psychological changes experienced with age.
3. Discuss nursing actions to promote health and reduce risks associated
with age-related changes.
TERMS TO KNOW
Crystallized intelligenceknowledge accumulated over a lifetime; arises
from the dominant hemisphere of the brain
Fluid intelligenceinvolves new information emanating from the
nondominant hemisphere; controls emotions, retention of
nonintellectual information, creative capacities, spatial perceptions, and
aesthetic appreciation
Immunosenescencethe aging of the immune system
PresbycusisProgressive, irreversible hearing loss that occurs as a result of
age-related changes to the inner ear
Presbyesophagusa condition characterized by a decreased intensity of
propulsive waves and an increased frequency of nonpropulsive waves
in the esophagus
Presbyopiathe inability to focus or accommodate properly due to reduced
elasticity of the lens that results from aging
Living is a process of continual change. Infants become toddlers,

prepubescent children blossom into young men and women, and dependent
adolescents develop into responsible adults. The continuation of change
into later life is natural and expected.
The type, rate, and degree of physical, emotional, psychological, and
social changes experienced during life are highly individualized; such
changes are influenced by genetic factors, environment, diet, health, stress,
lifestyle choices, and numerous other elements. The result is not only
individual variations among older persons but also differences in the pattern
of aging of various body systems within the same individual. Although
some similarities exist in the patterns of aging among individuals, the
pattern of aging is unique in each person.
CHANGES TO THE BODY
Cells
Organ and system changes can be traced to changes at the basic cellular
level. The number of cells is gradually reduced, leaving fewer functional
cells in the body. Lean body mass is reduced, whereas fat tissue increases
until the sixth decade of life. Total body fat as a proportion of the body’s
composition increases, and its distribution changes (e.g., an increase in
visceral fat level) (He et al., 2018). Cellular solids and bone mass are
decreased. Extracellular fluid remains fairly constant, whereas intracellular
fluid is decreased, resulting in less total body fluid. This decrease makes
dehydration a significant risk to older adults.
Physical Appearance
Many physical changes of aging affect a person’s appearance (Fig. 5-1).
Some of the more noticeable effects of the aging process begin to appear
after the fourth decade of life. It is then that men experience hair loss, and
both sexes develop gray hair and wrinkles. As body fat atrophies, the
body’s contours gain a bony appearance along with a deepening of the
hollows of the intercostal and supraclavicular spaces, orbits, and axillae.
Elongated ears, a double chin, and baggy eyelids are among the more
obvious manifestations of the loss of tissue elasticity throughout the body.
Skinfold thickness is significantly reduced in the forearm and on the back
of the hands. The loss of subcutaneous fat content, responsible for the
decrease in skinfold thickness, is also responsible for a decline in the body’s
natural insulation, making older adults more sensitive to cold temperatures.
FIGURE 5-1 Age-related changes noticeable on
inspection.
Stature decreases, resulting in a loss of as much as 3 in. in height by 80

years of age. Body shrinkage is due to reduced hydration, loss of cartilage,
and thinning of the vertebrae. The decrease in stature causes the long bones
of the body, which do not shrink, to appear disproportionately long. Any
curvature of the spine, hips, and knees that may be present can further
reduce height.
These changes in physical appearance are gradual and subtle. Further
differences in physiologic structure and function can arise from changes to
specific body systems.
Respiratory System
The changes to the respiratory system are apparent at the entrance to the
system with changes to the nose. Connective tissue changes cause a
relaxation of the tissue at the lower edge of the septum; the reduced support
causes the tip of the nose to slightly rotate downward. Septal deviations can
occur, as well. Mouth breathing during sleep becomes more common as a
result, contributing to snoring and obstructive apnea. The submucosal
glands have decreased secretions, reducing the ability to dilute mucus
secretion; the thicker secretions are more difficult to remove and give the
older person a sensation of nasal stuffiness.
Various structural changes occur in the chest with age that reduce
respiratory activity (Fig. 5-2). The calcification of costal cartilage makes
the trachea and rib cage more rigid; the anterior–posterior chest diameter
increases, often demonstrated by kyphosis; and thoracic inspiratory and
expiratory muscles are weaker. There is a blunting of the cough and
laryngeal reflexes. In the lungs, cilia reduce in number and there is
hypertrophy of the bronchial mucous gland, further complicating the ability
to expel mucus and debris. Alveoli reduce in number and stretch due to a
progressive loss of elasticity—a process that begins by the sixth decade of
life. The lungs become smaller, less firm, lighter, and more rigid and have
less recoil.
FIGURE 5-2 Respiratory changes that occur with aging.
The sum of these changes causes less lung expansion, insufficient

basilar inflation, and decreased ability to expel foreign or accumulated
matter. The lungs exhale less effectively, thereby increasing the residual
volume. As the residual volume increases, the vital capacity is reduced;
maximum breathing capacity also decreases. Immobility can further reduce
respiratory activity. The decline in ventilatory capacity is noticeable
primarily when an extra breathing demand is present, as the lower
pulmonary reserve results in dyspnea more easily occurring. With less
effective gas exchange and lack of basilar inflation, older adults are at high
risk for developing respiratory infections. Endurance training can produce a
significant increase in lung capacity of older adults.
Some cardiovascular changes commonly attributed to age actually result
from pathological conditions. Heart size does not change significantly due
to age; rather, enlarged hearts are associated with cardiac disease, and
marked inactivity can cause cardiac atrophy. There is a slight left
ventricular hypertrophy with age, and the aorta becomes dilated and
elongated. Atrioventricular valves become thick and rigid as a result of
sclerosis and fibrosis, compounding the dysfunction associated with any
cardiac disease that may be present. There may be incomplete valve closure
resulting in systolic and diastolic murmurs. Extra systolic sinus bradycardia
and sinus arrhythmia can occur in relation to irritability of the myocardium.
Age-related physiologic changes in the cardiovascular system appear in
a variety of ways (Fig. 5-3). Throughout the adult years, the heart muscle
loses its efficiency and contractile strength, resulting in reduced cardiac
output under conditions of physiologic stress. Pacemaker cells become
increasingly irregular and decrease in number, and the shell surrounding the
sinus node thickens. The isometric contraction phase and relaxation time of
the left ventricle are prolonged; the cycle of diastolic filling and systolic
emptying requires more time to be completed.
FIGURE 5-3 Cardiovascular changes that occur with
aging.

Incomplete valve closures can result in systolic and diastolic murmurs in
older adults. Diastolic filling and systolic emptying do not decrease with
age but take more time to be completed.
Usually, adults adjust to changes in the cardiovascular system quite

well; they learn that it is easier and more comfortable for them to take an
elevator rather than the stairs, to drive instead of walking a long distance,
and to pace their activities. When unusual demands are placed on the heart
(e.g., shoveling snow for the first time of the season, receiving bad news,
and running to catch a bus), the person feels the effects. The same holds
true for older individuals who are not severely affected by less cardiac
efficiency under nonstressful conditions. When older persons are faced with
an added demand on their hearts, however, they note the difference.
Although the peak rate of the stressed heart may not reach the levels
experienced by younger persons, tachycardia in older people will last for a
longer time. Stroke volume may increase to compensate for this situation,
which results in elevated blood pressure, although the blood pressure can
remain stable as tachycardia progresses to heart failure in older adults. The
resting heart rate is unchanged.
KEY CONCEPT
Age-related cardiovascular changes are most apparent when unusual
demands are placed on the heart.
Maximum exercise capacity and maximum oxygen consumption vary

among older people. Older adults in good physical condition have
comparable cardiac function to younger persons who are in poor condition.
Blood vessels consist of three layers, each of which is affected
differently by the aging process. The tunica intima, the innermost layer,
experiences the most direct changes, including fibrosis, calcium and lipid
accumulation, and cellular proliferation. These changes contribute to the
development of atherosclerosis. The middle layer, the tunica media,
undergoes a thinning and calcification of elastin fibers and an increase in
collagen, which cause a stiffening of the vessels. Impaired baroreceptor
function and increased peripheral resistance occur, which can lead to a rise
in systolic blood pressure. Interestingly, although a gradual increase in
blood pressure is common in the United States and other industrialized
nations, it does not tend to occur in less industrialized societies; cross-
cultural studies that currently are being conducted will help to clarify if the
rise in blood pressure is a result of normal aging or other factors. The
outermost layer, the tunica adventitia, is not affected by the aging process.
Decreased elasticity of the arteries is responsible for vascular changes to the
heart, kidney, and pituitary gland. Reduced sensitivity of the blood
pressure–regulating baroreceptors increases problems with postural
hypotension and postprandial hypotension (blood pressure reduction of at
least 20 mm Hg within 1 hour of eating). The reduced elasticity of the
vessels, coupled with thinner skin and less subcutaneous fat, causes the
vessels in the head, neck, and extremities to become more prominent.
Although not as life threatening as respiratory or cardiovascular problems,
gastrointestinal symptoms may be of more bother and concern to older
persons. This system is altered by the aging process at all points. Changes
in the teeth and mouth and accessory structures such as the liver also affect
gastrointestinal function. Figure 5-4 summarizes gastrointestinal system
changes.
FIGURE 5-4 Gastrointestinal changes that occur with
aging.
Tooth enamel becomes harder and more brittle with age. Dentin, the
layer beneath the enamel, becomes more fibrous and its production is
decreased. The nerve chambers become narrower and shorter and teeth are
less sensitive to stimuli. The root pulp experiences shrinkage and fibrosis,
the gingiva retracts, and bone density in the alveolar ridge is lost. Increasing
numbers of root cavities and cavities around existing dental work occur.
Flattening of the chewing cusps is common. The bones that support the
teeth decrease in density and height, contributing to tooth loss. Tooth loss is
not a normal consequence of growing old, but poor dental care, diet,
smoking, and environmental influences have contributed to many of today’s
older population being edentulous. After 30 years of age, periodontal
disease is the major reason for tooth loss. More than half of all older adults
must rely on partial or full dentures, which may not be worn regularly
because of discomfort or poor fit. If natural teeth are present, they often are
in poor condition; fracture easier; and have flatter surfaces, stains, and
varying degrees of erosion and abrasion of the crown and root structure.
The tooth brittleness of some older people creates the possibility of
aspiration of tooth fragments.
Taste sensations become less acute with age because the tongue
atrophies, affecting the taste buds; chronic irritation (as from pipe smoking)
can reduce taste efficiency to a greater degree than that experienced through
aging alone. The sweet sensations on the tip of the tongue tend to suffer a
greater loss than the sensations for sour, salt, and bitter flavors. Excessive
seasoning of foods may be used to compensate for taste alterations and
could lead to health problems for older individuals. Loss of papillae and
sublingual varicosities on the tongue are common findings.
Older adults produce approximately one third of the amount of saliva
they produced in younger years (Xu, Laguna, & Sarkar, 2019). Saliva often
is diminished in quantity and is of increased viscosity as a result of some of
the medications commonly used to treat geriatric conditions. Salivary
ptyalin is decreased, interfering with the breakdown of starches. Diminished
muscle strength and tongue pressure can interfere with mastication and
swallowing (Peyron, Woda, Bourdiol, & Hennequin, 2017).
Esophageal motility is affected by age. Presbyesophagus is a condition
characterized by a decreased intensity of propulsive waves and an increased
frequency of nonpropulsive waves in the esophagus. The esophagus tends
to become slightly dilated, and esophageal emptying is slower, which can
cause discomfort because food remains in the esophagus for a longer time.
Relaxation of the lower esophageal sphincter may occur; when combined
with the older person’s weaker gag reflex and delayed esophageal
emptying, aspiration becomes a risk.
The stomach is believed to have reduced motility in old age, along with
decreases in hunger contractions. Studies regarding changes in gastric
emptying time have been inconclusive, with some claiming delayed gastric
emptying to occur with normal aging and others attributing it to other
factors. The gastric mucosa atrophies. Hydrochloric acid and pepsin decline
with age; the higher pH of the stomach contributes to an increased
incidence of gastric irritation in the older population.
Some atrophy occurs throughout the small and large intestines, and
fewer cells are present on the absorbing surface of intestinal walls. There is
a gradual reduction in the weight of the small intestine and shortening and
widening of the villi, leading to them developing the shape of parallel
ridges rather than the finger-like projections of earlier years. Functionally,
there is no significant change in mean small bowel transit time with age. Fat
absorption is slower, and dextrose and xylose are more difficult to absorb.
Absorption of vitamin B, vitamin B12, vitamin D, calcium, and iron is
faulty. The large intestine has reductions in mucous secretions and elasticity
of the rectal wall. Normal aging does not interfere with the motility of feces
through the bowel, although other factors that are highly prevalent in late
life do contribute to constipation. An age-related loss of tone of the internal
sphincter can affect bowel elimination. Slower transmission of neural
impulses to the lower bowel reduces awareness of the need to evacuate the
bowels.
With advancing age, the liver has reduced weight and volume but this
seems to produce no ill effects. The older liver is less able to regenerate
damaged cells. Liver function tests remain within a normal range. Less
efficient cholesterol stabilization and absorption cause an increased
incidence of gallstones. The pancreatic ducts become dilated and distended,
and often, the entire gland prolapses.
Urinary System
The urinary system is affected by changes in the kidneys, ureters, and
bladder (Fig. 5-5). The renal mass becomes smaller with age, which is
attributable to a cortical loss rather than a loss of the renal medulla. Renal
tissue growth declines, and atherosclerosis may promote atrophy of the
kidney. These changes can have a profound effect on renal function,
reducing renal blood flow and the glomerular filtration rate by
approximately one half between the ages of 20 and 90 years (Denic,
Glassrock, & Rule, 2016).
FIGURE 5-5 Urinary tract changes that occur with aging.

Tubular function decreases. There is less efficient tubular exchange of
substances, conservation of water and sodium, and suppression of
antidiuretic hormone secretion in the presence of hypo-osmolality. Older
kidneys have less ability to conserve sodium in response to sodium
restriction. Although these changes can contribute to hyponatremia and
nocturia, they do not affect specific gravity to any significant extent. The
decrease in tubular function also causes decreased reabsorption of glucose
from the filtrate, which can cause 1+ proteinurias and glycosurias not to be
of major diagnostic significance.
Urinary frequency, urgency, and nocturia accompany bladder changes
with age. Bladder muscles weaken and bladder capacity decreases.
Emptying of the bladder is more difficult; retention of large volumes of
urine may result. The micturition reflex is delayed. Although urinary
incontinence is not a normal outcome of aging, some stress incontinence
may occur because of a weakening of the pelvic diaphragm, particularly in
multiparous women.
Reproductive System
As men age, the seminal vesicles are affected by a smoothing of the
mucosa, thinning of the epithelium, replacement of muscle tissue with
connective tissue, and reduction of fluid-retaining capacity. The
seminiferous tubules experience increased fibrosis, thinning of the
epithelium, thickening of the basement membrane, and narrowing of the
lumen. The structural changes can cause a reduction in sperm count in some
men. Increases in follicle-stimulating and luteinizing hormone levels occur,
along with decreases in both serum and bioavailable testosterone levels.
Venous and arterial sclerosis and fibroelastosis of the corpus spongiosum
can affect the penis with age. The older man does not lose the physical
capacity to achieve erections or ejaculations, although orgasm and
ejaculation tend to be less intense (Gunes, Hekim, Arslan, & Asci, 2016).
There is some atrophy of the testes.
Prostatic enlargement occurs in most older men (Liu et al., 2019). The
rate and type vary among individuals. Three fourths of men aged 65 years
and older have some degree of prostatism, which causes problems with
urinary frequency. Although most prostatic enlargement is benign, it does
pose a greater risk of malignancy and requires regular evaluation.
The female genitalia demonstrate many changes with age, including
atrophy of the vulva from hormonal changes, accompanied by the loss of
subcutaneous fat and hair and a flattening of the labia. The vagina of the
older woman appears pink and dry with a smooth, shiny canal because of
the loss of elastic tissue and rugae. The vaginal epithelium becomes thin
and avascular. The vaginal environment is more alkaline in older women
and is accompanied by a change in the type of flora and a reduction in
secretions. The cervix atrophies and becomes smaller; the endocervical
epithelium also atrophies. The uterus shrinks and the endometrium
atrophies; however, the endometrium continues to respond to hormonal
stimulation, which can be responsible for incidents of postmenopausal
bleeding in older women on estrogen therapy. The ligaments supporting the
uterus weaken and can cause a backward tilting of the uterus; this backward
displacement along with the reduced size of the uterus can make it difficult
to palpate during an examination. The fallopian tubes atrophy and shorten
with age, and the ovaries atrophy and become thicker and smaller. The
ovaries can shrink to such a small size that they are not palpable during an
examination. Despite these changes, the older woman does not lose the
ability to engage in and enjoy intercourse or other forms of sexual pleasure.
Estrogen depletion also causes a weakening of pelvic floor muscles, which
can lead to an involuntary release of urine when there is an increase in
intra-abdominal pressure.
Figure 5-6 summarizes age-related changes in male and female
reproductive systems.
FIGURE 5-6 Changes in male and female reproductive
structures that occur with aging.
The kyphosis, enlarged joints, flabby muscles, and decreased height of
many older persons result from the variety of musculoskeletal changes
occurring with age (Fig. 5-7). Along with other body tissue, muscle fibers
atrophy and decrease in number, with fibrous tissue gradually replacing
muscle tissue. Overall muscle mass, muscle strength, and muscle
movements are decreased; the arm and leg muscles, which become
particularly flabby and weak, display these changes well. Sarcopenia, the
age-related loss of muscle mass, strength, and function, is mostly seen in
inactive persons; thus, the importance of exercise to minimize the loss of
muscle tone and strength cannot be emphasized enough. Muscle tremors
may be present and are believed to be associated with degeneration of the
extrapyramidal system. The tendons shrink and harden, which causes a
decrease in tendon jerks. Reflexes are lessened in the arms, are nearly
totally lost in the abdomen, but are maintained in the knee. For various
reasons, muscle cramping frequently occurs.
FIGURE 5-7 Skeletal changes that occur with aging.
Bone mineral and bone mass are reduced, contributing to the brittleness
of the bones of older people, especially older women who experience an
accelerated rate of bone loss after menopause. Bone density decreases at a
rate of 0.5% each year after the third decade of life. There is diminished
calcium absorption, a gradual resorption of the interior surface of the long
bones, and a slower production of new bone on the outside surface. These
changes make fractures a serious risk to the older adults. Although long
bones do not significantly shorten with age, thinning disks and shortening
vertebrae reduce the length of the spinal column, causing a reduction in
height with age. Height may be further shortened because of varying
degrees of kyphosis, a backward tilting of the head, and some flexion at the
hips and knees. A deterioration of the cartilage surface of joints and the
formation of points and spurs may limit joint activity and motion.
Nervous System
It is difficult to identify with accuracy the exact impact of aging on the
nervous system because of the dependence of this system’s function on
other body systems. For instance, cardiovascular problems can reduce
cerebral circulation and be responsible for cerebral dysfunction. There is a
decline in brain weight and a reduction in blood flow to the brain; however,
these structural changes do not appear to affect thinking and behavior
(Carter, 2019). Declining nervous system function may be unnoticed
because changes are often nonspecific and slowly progressing.
A reduction in neurons, nerve fibers, cerebral blood flow, and
metabolism is known to occur. Reduced cerebral blood flow is accompanied
by a reduction in glucose utilization and metabolic rate of oxygen in the
brain. Electroencephalograms show a decrease in functional connections
(Moezzi et al., 2019). Although β-amyloid and neurofibrillary tangles are
associated with Alzheimer’s disease, they can be present in older adults
with normal cognitive function.
The nerve conduction velocity is lower (Fig. 5-8). These changes are
manifested by slower reflexes and delayed response to multiple stimuli.
Kinesthetic sense lessens. There is a slower response to changes in balance,
a factor contributing to falls. Slower recognition and response to stimuli is
associated with a decrease in new axon growth and nerve reinnervation of
injured peripheral nerves.
FIGURE 5-8 Neurologic changes that occur with aging.
The hypothalamus regulates temperature less effectively. Brain cells

slowly decline over the years, the cerebral cortex undergoes some loss of
neurons, and there is some decrease in brain size and weight, particularly
after age 55 years. Because the brain affects the sleep–wake cycle, and
circadian and homeostatic factors of sleep regulation are altered with aging,
changes in the sleep pattern occur, with stages III and IV of sleep becoming
less prominent (Mander, Winer, & Walker, 2017). Frequent awakening
during sleep is not unusual, although only a minimal amount of sleep is
actually lost.
Sensory Organs
Each of the five senses becomes less efficient with advanced age,
interfering in varying degrees with safety, normal activities of daily living,
and general well-being (Fig. 5-9).
FIGURE 5-9 Effects of sensory changes that occur with

aging.
Vision
Perhaps the sensory changes having the greatest impact are changes in
vision. Presbyopia , the inability to focus or accommodate properly due to
reduced elasticity of the lens, is characteristic of older eyes and begins in
the fourth decade of life. The stiffening of the muscle fibers of the lens that
occurs with presbyopia decreases the eye’s ability to change the shape of
the lens to focus on near objects and decreases the ability to adapt to light.
This vision problem causes most middle-aged and older adults to need
corrective lenses to accommodate close and detailed work. The visual field
narrows, making peripheral vision more difficult. There is difficulty
maintaining convergence and gazing upward. The pupil is less responsive to
light because the pupillary sphincter hardens, the pupil size decreases, and
rhodopsin content in the rods decreases. As a result, the light perception
threshold increases and vision in dim areas or at night is difficult; older
individuals require more light than younger persons to see adequately.
Alterations in the blood supply of the retina and retinal pigmented
epithelium can cause macular degeneration, a condition in which there is a
loss in central vision. Changes in the retina and retinal pathway interfere
with critical flicker fusion (the point at which a flickering light is perceived
as continuous rather than intermittent).
The density and size of the lens increase, causing the lens to become
stiffer and more opaque. Opacification of the lens, which begins in the fifth
decade, leads to the development of cataracts, which increases sensitivity to
glare, blurs vision, and interferes with night vision. Exposure to the
ultraviolet rays of the sun contributes to cataract development. Yellowing of
the lens (possibly related to a chemical reaction involving sunlight with
amino acids) and alterations in the retina that affect color perception make
older people less able to differentiate the low-tone colors of the blues,
greens, and violets.
Depth perception becomes distorted, causing problems in correctly
judging the height of curbs and steps. This change results from a disparity
between the retinal images caused by the separation of the two eyes and is
known as stereopsis. Dark and light adaptation takes longer, as does the
processing of visual information. Less efficient reabsorption of intraocular
fluid increases the older person’s risk of developing glaucoma. The ciliary
muscle gradually atrophies and is replaced with connective tissue.
The appearance of the eye may be altered; reduced lacrimal secretions
can cause the eyes to look dry and dull, and fat deposits can cause a partial
or complete glossy white circle to develop around the periphery of the
cornea (arcus senilis). Corneal sensitivity is diminished, which can increase
the risk of injury to the cornea. The accumulation of lipid deposits in the
cornea can cause a scattering of light rays, which blurs vision. In the
posterior cavity, bits of debris and condensation become visible and may
float across the visual field; these are commonly called floaters. Vitreous
decreases and the proportion of liquid increases, causing the vitreous body
to pull away from the retina; blurred vision, distorted images, and floaters
may result. Visual acuity progressively declines with age due to decreased
pupil size, scatter in the cornea and lens, opacification of the lens and
vitreous, and loss of photoreceptor cells in the retina.
Hearing
Presbycusis is progressive hearing loss that occurs as a result of age-related
changes to the inner ear, including loss of hair cells, decreased blood
supply, reduced flexibility of basilar membrane, degeneration of spiral
ganglion cells, and reduced production of endolymph. This degenerative
hearing impairment is the most serious problem affecting the inner ear and
retrocochlea. High-frequency sounds of 2,000 Hz and above are the first to
be lost; middle and low frequencies also may be lost as the condition
progresses. A variety of factors, including continued exposure to loud noise,
may contribute to the occurrence of presbycusis. This problem causes
speech to sound distorted as some of the high-pitched sounds (s, sh, f, ph,
and ch) are filtered from normal speech and consonants are less able to be
discerned. This change is so gradual and subtle that affected persons may
not realize the extent of their hearing impairment. Hearing can be further
jeopardized by an accumulation of cerumen in the middle ear; the higher
keratin content of cerumen as one ages contributes to this problem. The
acoustic reflex, which protects the inner ear and filters auditory distractions
from sounds made by one’s own body and voice, is diminished due to a
weakening and stiffening of the middle ear muscles and ligaments. In
addition to hearing problems, equilibrium can be altered because of
degeneration of the vestibular structures and atrophy of the cochlea, organ
of Corti, and stria vascularis.
KEY CONCEPT
Although hearing declines with age, impaired hearing can occur at
younger ages due to exposure to loud music, traffic, and other
environmental noise. This noise-induced hearing loss is preventable.
Taste and Smell

Most older persons experience some loss of their ability to smell. The sense
of smell reduces with age because of a decrease in the number of sensory
cells in the nasal lining and fewer cells in the olfactory bulb of the brain. By
age 80 years, the detection of scent is almost half as sensitive as it was at its
peak. Men tend to experience a greater loss in the ability to detect odors
than women.
As most of the taste acuity is dependent on smell, the reduction in the
sense of smell alters the sense of taste. Atrophy of the tongue with age can
diminish taste sensations, although there is no conclusive evidence that the
number or responsiveness of taste buds decreases (Ogawa, Annear, Ikebe,
& Maeda, 2017). The ability to detect salt is affected more than other taste
sensations. Reduced saliva production, poor oral hygiene, medications, and
conditions such as sinusitis can also affect taste.
Touch
A reduction in the number of and changes in the structural integrity of touch
receptors occurs with age. Tactile sensation is reduced, as observed in the
reduced ability of older persons to sense pressure and pain and differentiate
temperatures. These sensory changes can cause misperceptions of the
environment and, as a result, profound safety risks.
Endocrine System
The endocrine system has groups of cells and glands that produce the
chemical messengers known as hormones. With age, the thyroid gland
undergoes fibrosis, cellular infiltration, and increased nodularity. The
resulting decreased thyroid gland activity causes a lower basal metabolic
rate, reduced radioactive iodine uptake, and less thyrotropin secretion and
release. Protein-bound iodine levels in the blood do not change, although
total serum iodide is reduced. The release of thyroidal iodide decreases with
age, and excretion of the 17-ketosteroids declines. The thyroid gland
progressively atrophies, and the loss of adrenal function can further
decrease thyroid activity. Secretion of thyroid-stimulating hormone (TSH)
and the serum concentration of thyroxine (T4) do not change, although
there is a significant reduction in triiodothyronine (T3), believed to be a
result of the reduced conversion of T4 to T3. Overall, the thyroid function
remains adequate.
Much of the secretory activity of the adrenal cortex is regulated by
adrenocorticotropic hormone (ACTH), a pituitary hormone. As ACTH
secretion decreases with age, secretory activity of the adrenal gland also
decreases. Although the secretion of ACTH does not affect aldosterone
secretion, it has been shown that less aldosterone is produced and excreted
in the urine of older persons. The secretion of glucocorticoids, 17-
ketosteroids, progesterone, androgen, and estrogen, also influenced by the
adrenal gland, is reduced as well.
The pituitary gland decreases in volume by approximately 20% in older
persons. Somatotropic growth hormone remains present in similar amounts,
although the blood level may be reduced with age. Decreases are seen in
ACTH, TSH, follicle-stimulating hormone, luteinizing hormone, and
luteotropic hormone to varying degrees. Gonadal secretion declines with
age, including gradual decreases in testosterone, estrogen, and
progesterone. With the exception of alterations associated with changes in
plasma calcium level or dysfunction of other glands, the parathyroid glands
maintain their function throughout life.
There is a delayed and insufficient release of insulin by the beta cells of
the pancreas in older people, and there is believed to be decreased tissue
sensitivity to circulating insulin. The older person’s ability to metabolize
glucose is reduced, and sudden concentrations of glucose cause higher and
more prolonged hyperglycemia levels; acute medical conditions, surgery, or
trauma also can increase blood glucose levels in older individuals. For these
reasons, it is not unusual to detect higher blood glucose levels in
nondiabetic older adults.
KEY CONCEPT
Higher blood glucose levels than are normal in the general adult
population are not unusual to find in nondiabetic older people.
Diet, general health, activity, exposure, and hereditary factors influence the
normal course of aging of the skin. This system’s changes are often the
most bothersome because they are obvious and clearly reflect advancing
years. Flattening of the dermal–epidermal junction, reduced thickness and
vascularity of the dermis, slowing of epidermal proliferation, and an
increased quantity and degeneration of elastin fibers occur. Collagen fibers
become coarser and more random, reducing skin elasticity. The dermis
becomes more avascular and thinner. As the skin becomes less elastic and
more dry and fragile, and as subcutaneous fat is lost, lines, wrinkles, and
sagging become evident. Skin becomes irritated and breaks down more
easily. There is a reduction in the number of melanocytes by 10% to 20%
each decade beginning by the third decade of life, and the melanocytes
cluster, causing skin pigmentation, commonly referred to as age spots; these
are more prevalent in areas of the body exposed to the sun. The reduction in
melanocytes causes older adults to tan more slowly and less deeply. Skin
immune response declines, causing older people to be more prone to skin
infections. Benign and malignant skin neoplasms occur more with age.
Scalp, pubic, and axillary hair thins and grays due to a progressive loss
of pigment cells and atrophy and fibrosis of hair bulbs; hair in the nose and
ears becomes thicker. By age 50 years, most white men have some degree
of baldness and about half of all people have evidence of gray hair. Growth
rate of scalp, pubic, and axillary hair declines; the growth of facial hair may
occur in older women. An increased growth of eyebrow, ear, and nostril hair
occurs in older men. Fingernails grow more slowly, are fragile and brittle,
develop longitudinal striations, and experience a decrease in lunula size.
Perspiration is slightly reduced because the number and function of the
sweat glands are lessened.
Immune System
The aging of the immune system, known as immunosenescence , includes
a depressed immune response, which can cause infections to be a
significant risk of older adults. After midlife, thymic mass decreases
steadily, to the point that serum activity of thymic hormones is almost
undetectable in the aged. T-cell activity declines and more immature T cells
are present in the thymus. A significant decline in cell-mediated immunity
occurs, and T lymphocytes are less able to proliferate in response to
mitogens. Changes in the T cells contribute to the reactivation of varicella
zoster and Mycobacterium tuberculosis, infections that are witnessed in
many older individuals. Serum immunoglobulin (Ig) concentration is not
significantly altered; the concentration of IgM is lower, whereas the
concentrations of IgA and IgG are higher. Responses to influenza,
parainfluenza, pneumococcus, and tetanus vaccines are less effective
(although vaccination is recommended because of serious potential
consequences of infections for older adults). Inflammatory defenses
decline, and, often, inflammation presents atypically in older individuals
(e.g., low-grade fever and minimal pain). In addition, an increase in
proinflammatory cytokines occurs with age, which is believed to be linked
to atherosclerosis, diabetes, osteoporosis, and other diseases that increase in
prevalence with age.
In addition to maintaining a good nutritional state, older people can
include foods in their diet that positively affect immunity, such as milk,
yogurt, nonfat cottage cheese, eggs, fresh fruits and vegetables, nuts, garlic,
onion, sprouts, pure honey, and unsulfured molasses. A daily multivitamin
and mineral supplement is also helpful. Regular physical activity can
enhance immune function, including exercises such as yoga and t’ai chi,
which are low impact and have a positive effect on immunity. Stress can
affect the function of the immune system because elevated cortisol levels
can lead to a breakdown in lymphoid tissue, inhibition of the production of
natural killer cells, increases in T-suppressor cells, and reductions in the
levels of T-helper cells and virus-fighting interferon.
Thermoregulation
Normal body temperatures are lower in later life than in younger years, with
mean body temperatures ranging from 96.4°F to 98.5°F orally, 97.1°F to
99.2°F rectally, 96°F to 97.4°F axillary, and 96.4°F to 99.5°F via auditory
canal. Rectal and auditory canal temperatures are the most accurate and
reliable indicators of body temperature in older adults.
There is a reduced ability to respond to cold temperatures due to
inefficient vasoconstriction, reduced peripheral circulation, decreased
cardiac output, diminished shivering, and reduced muscle mass and
subcutaneous tissue. At the other extreme, differences in response to heat
are related to impaired sweating mechanisms and decreased cardiac output.
These age-related changes cause older adults to be more susceptible to heat
stress. Alterations in response to cold and hot environments increase the
risks for accidental hypothermia, heat exhaustion, and heat stroke.
Unfolding Patient Stories: Sherman “Red”

Yoder • Part 1
Sherman “Red” Yoder, age 80, lives alone on
his farm, which is managed by his son, Jon, who lives nearby. Red drives
20 miles into town at least once a week to visit with friends. The home
health nurse has come to evaluate his diabetes management and an open
foot wound. Red’s daughter-in-law, Judy, has expressed concern about his
driving ability. How does the nurse initiate the discussion with Red to
assess his ability to drive safely? What age-related changes and conditions
can increase the risk for unsafe driving? What interventions should the
nurse consider if driving risks are identified? (Red Yoder’s story continues
in Chapter 14.)
Care for Red and other patients in a realistic virtual environment:
CHANGES TO THE MIND

Psychological changes can be influenced by general health status, genetic
factors, educational achievement, activity, and physical and social changes.
Sensory organ impairment can impede interaction with the environment and
other people, thus influencing psychological status. Feeling depressed and
socially isolated may obstruct optimum psychological function.
Recognizing the variety of factors potentially affecting psychological status
and the range of individual responses to those factors, some generalizations
can be discussed.
Personality
Drastic changes in basic personality normally do not occur as one ages. The
kind and gentle old person was most likely that way when young; likewise,
the cantankerous old person probably was not mild and meek in earlier
years. Excluding pathologic processes, the personality will be consistent
with that of earlier years; possibly, it will be more openly and honestly
expressed. The alleged rigidity of older persons is more a result of physical
and mental limitations than a personality change. For example, an older
person’s insistence that her furniture not be rearranged may be interpreted
as rigidity, but it may be a sound safety practice for someone coping with
poor memory and visual deficits. Changes in personality traits may occur in
response to events that alter self-attitude, such as retirement, death of a
spouse, loss of independence, income reduction, and disability. No
personality type describes all older adults; personality in late life is a
reflection of lifelong personality. Morale, attitude, and self-esteem tend to
be stable throughout the life span.
Memory
Memory generally declines with age. Often what is most noticeable is
poorer short-term memory, which affects the ability to recall recently
acquired information, like a phone number that has just been given.
Memories of dates, locations, emotions, and other contextual information,
known as episodic memory, declines with age, as does semantic memory,
which allows retrieval of general knowledge stored throughout one’s life.
The ability to retain information in the consciousness while manipulating
other information—working memory function—is reduced. Older adults
can improve some age-related forgetfulness by using memory aids
(mnemonic devices) such as associating a name with an image, making
notes or lists, and placing objects in consistent locations. Memory deficits
can result from a variety of factors other than normal aging.
Intelligence
In general, it is wise to interpret the findings related to intelligence and the
older population with much caution because results may be biased from the
measurement tool or method of evaluation used. Early gerontological
research on intelligence and aging was guilty of such biases. Sick old
people cannot be compared with healthy persons; people with different
educational or cultural backgrounds cannot be compared; and one group of
individuals who are skilled and capable of taking an IQ test cannot be
compared with those who have sensory deficits and may not have ever
taken this type of test. Longitudinal studies that measure changes in a
specific generation as it ages and that compensate for sensory, health, and
educational deficits are relatively recent, and they serve as the most
accurate way of determining intellectual changes with age.
Basic intelligence is maintained; one does not become more or less
intelligent with age. The abilities for verbal comprehension and arithmetic
operations are unchanged. Crystallized intelligence , which is the
knowledge accumulated over a lifetime and arises from the dominant
hemisphere of the brain, is maintained through the adult years; this form of
intelligence enables the individual to use past learning and experiences for
problem solving. Fluid intelligence , involving new information and
emanating from the nondominant hemisphere, controls emotions, retention
of nonintellectual information, creative capacities, spatial perceptions, and
aesthetic appreciation; this type of intelligence is believed to decline in later
life. Some decline in intellectual function occurs in the moments preceding
death.
COMMUNICATION TIP
Altered vision and hearing, the need for more time to process new
information, and the stress of an interaction with a health care
professional can prevent older adults from contributing valuable
information during the assessment process and block them from
hearing instructions. While respecting the individual’s level of
function, employ these strategies: Allow time for questions to be
answered, provide examples to trigger memory, and reinforce
instructions through repetition and supplementing oral instructions
with written ones.
Learning
Although learning ability is not seriously altered with age, other factors can
interfere with the older person’s ability to learn, including motivation,
attention span, delayed transmission of information to the brain, perceptual
deficits, and illness. Older persons may display less readiness to learn and
depend on previous experience for solutions to problems rather than
experiment with new problem-solving techniques. Differences in the
intensity and duration of the older person’s physiologic arousal may make it
more difficult to extinguish previous responses and acquire new material.
The early phases of the learning process tend to be more difficult for older
persons than younger individuals; however, after a longer early phase, they
are then able to keep equal pace. Learning occurs best when the new
information is related to previously learned information. Although little
difference is apparent between the old and young in verbal or abstract
ability, older persons do show some difficulty with perceptual motor tasks.
Some evidence indicates a tendency toward simple association rather than
analysis. Because it is generally a greater problem to learn new habits when
old habits exist and must be unlearned, relearned, or modified, older
persons with many years of history may have difficulty in this area.
KEY CONCEPT
Older adults maintain the capacity to learn, although a variety of factors
can easily interfere with the learning process.
Attention Span
Older adults demonstrate a decrease in vigilance performance (i.e., the
ability to retain attention longer than 45 minutes). They are more easily
distracted by irrelevant information and stimuli and are less able to perform
tasks that are complicated or require simultaneous performance.
POINT TO PONDER
In the past 10 years, what changes have you experienced in regard to
appearance, behaviors, and attitudes? How do you feel about these
changes?
NURSING IMPLICATIONS OF AGE-

RELATED CHANGES
An understanding of common aging changes is essential to ensure
competent gerontological nursing practice. Such knowledge can aid in
promoting practices that enhance wellness, thereby reducing risks to health
and well-being. Differentiating normal from unusual findings in older adults
and the atypical presentation of illness can be invaluable in identifying
pathology and obtaining treatment in a timely manner. Table 5-1 lists some
nursing actions related to age-related changes.
TABLE 5-1 Nursing Actions Related to Age-Related Changes

KEY CONCEPT
By promoting positive practices in persons of all ages, nurses can help
greater numbers of individuals enter late life with high levels of health
and function.
CONSIDER THIS CASE
Mr. G is a 72-year-old retired truck driver

admitted to the hospital for the treatment of acute glomerulonephritis. His
height is 5 ft 11 in., and his weight is 180 lb. You note from the record that
he weighed 220 lb last year and has experienced a reduction in weight at
each of his monthly physician’s visits. Although he has a moderate degree
of chronic obstructive pulmonary disease, he continues to smoke one pack
of cigarettes daily. He has varicosities on both lower extremities and
hemorrhoids. Mr. G is coherent and responds appropriately. His wife
comments that he has always had a sharp mind, although in the past few
years he has become considerably quieter and less gregarious. As you
observe Mr. G throughout the day, you note that he:
Becomes short of breath with minimal exertion

Develops edema
Has urinary hesitancy and scanty urine output
Adds considerable salt to his food before tasting it
Has difficulty hearing normal conversation
Moves very little when in bed
THINK CRITICALLY
1. Which signs and observations are related to normal aging and
which can you attribute to pathology?
2. What factors contributed to the health conditions possessed by

Mr. G?
3. Describe the risks that are high for Mr. G and list nursing
measures that could minimize them.
Nurses caring for older adults must realize that, despite the numerous
changes commonly experienced with age, most older adults function
admirably well and live normal, satisfying lives. Although nurses need to
acknowledge factors that can alter function with aging, they should also
emphasize the capabilities and assets possessed by older adults and assist
persons of all ages in achieving a healthy aging process.
Ten Years Younger: Practice of Chronic Aerobic

Exercise Improves Attention and Spatial Memory
Functions in Aging
Source: Noguera, C., Sanchez-Horcajo, R., Alvarez-Cazorla, D., &
Cimadevilla, J. M. (2019). Experimental Gerontology, 117(3), 53–60.
Physical activity can be particularly significant after age 60, when
cognitive decline is more apparent, because aerobic exercise has been
shown to change brain morphology and improve cognitive function. This
study compared sportsmen and sedentary men between the ages of 60 and
79 years.
Spatial memory and executive function were among the cognitive
functions that were superior in the sportsmen group as compared to the
sedentary group. Other neuropsychological tasks were also performed better
by the sportsmen.
Based on the positive effects of aerobic exercise on physical and
cognitive function, nurses should encourage aerobic exercises for all
individuals. Assessments should include a review of the exercises in which
individuals engage. Positive reinforcement can be given to those who
exercise. For those who do not regularly exercise, exploring the reasons,
discussing the benefits, and assisting them in developing a plan that it
realistic for them could assist in changing their behavior. In addition to
encouraging older adults to engage in aerobic exercise, promoting this type
of exercise in adults under the age of 65 can be beneficial so that this group
may establish the habit of exercise that they can continue into late life.
Older adults should be advised that aerobic exercise benefits their
minds as well as their bodies. That way, even individuals who are not
bothered by muscles that are not firm might be concerned about losing
cognitive function and, therefore, be more motivated to exercise.
PRACTICE REALITIES
You are working in an office with a group of medical doctors who have had
some of the same patients in their practice for nearly two decades. Although
many of their patients have aged, the physicians use basically the same
approach, reorder the same medications, and include no review of
psychosocial issues.
What could you suggest to update the practice to assure the needs of the
aging patients are adequately being addressed?
1. What efforts do you see to educate persons of all ages in practices that
will foster a healthy aging experience?
2. What age-related changes can you identify in yourself and in your
parents?
3. Consider recommendations that you would give young adults for
promotion of a healthy aging process.
Chapter Summary
Changes at the basic cellular level impact all body systems. The atrophy of
body fat, loss of tissue elasticity, and reduction in subcutaneous fat
contribute to changes in the appearance of the body with age. Changes to
body systems contribute to a higher prevalence in the older population of
conditions such as infections, hypertension, poor dental status, indigestion,
constipation, urinary frequency, prostatic enlargement, fractures, reduced
vision, presbycusis, hypothermia, and hyperthermia. Basic intelligence is
maintained, and there is some reduction in fluid intelligence. The ability to
retain new information is reduced, and the retrieval of information from
long-term memory can be slower. Learning ability is maintained, although
several factors that can interfere with learning. A variety of nursing actions
can be utilized to prevent and reduce the negative impact of aging changes
and promote optimal health and function in older adults.
References
Carter, R. (2019). The human brain: An illustrated guide to its structure, function, and disorders (pp.
214–215). New York, NY: DK Publishing.
Denic, A., Glassrock, R. J., & Rule, A. D. (2016). Structural and functional changes with the aging
kidney. Advances in Chronic Kidney Disease, 23 (1), 19–28.
Gunes, S., Hekim, G. N. T., Arslan, M. A., & Asci, R. (2016). Effects of aging on the male
reproductive system. Journal of Assisted Reproduction and Genetics, 33 (4), 441–454.
He, X., Li, Z., Tang, X., Zhang, L., Wang, L., He, Y., … Yuan, D. (2018). Age- and sex-related
differences in body composition in health subjects aged 18-32 years. Medicine, 97 (25).
Liu, T. T., Thomas, S., McLean, D. T., Roldan-Alzate, A., Hernando, D., Ricke, E. A., et al. (2019).
Prostate enlargement and altered urinary function are part of the aging process. Aging, 11 (9),
2653–2669.
Mander, B. A., Winer, J. R., & Walker, M. P. (2017). Sleep and human aging. Neuron, 94 (5), 19–36.
Moezzi, B., Pratti, L. M., Hordacre, B., Graetz, L., Berryman, C., Lavencic, L. M., et al. (2019).
Characterization of young and old adult brains: An EEG functional connectivity analysis.
Neuroscience, 422 (12), 230–239.
Ogawa, T., Annear, M. J., Ikebe, K., & Maeda, Y. (2017). Taste-related sensations in old age. Journal
of Oral Rehabilitation, 44 (8), 626–635.
Peyron, M. A., Woda, A., Bourdiol, F., & Hennequin, M. (2017). Age-related changes in mastication.
Journal of Oral Rehabilitation, 44 (4), 299–312.
Xu, F., Laguna, L., & Sarkar, A. (2019). Aging-related changes in quantity and quality of saliva:
Where do we stand in our understanding? Journal of Texture Studies, 50 (1), 27–35.
UNIT 2
Foundations of Gerontological
Nursing
CHAPTER 6
The Specialty of Gerontological
Nursing
Chapter Outline
Development of Gerontological Nursing
Core Elements of Gerontological Nursing Practice
Standards
Competencies
Principles
Gerontological Nursing Roles
Healer
Caregiver
Educator
Advocate
Innovator
Advanced Practice Nursing Roles
Self-Care and Nurturing
Strengthening and Building ConnectionsCommitting to a Dynamic
Process
The Future of Gerontological Nursing
Advance Research
Educate Caregivers
Develop New Roles
LEARNING OBJECTIVES
1. Describe the importance of evidence-based practice in gerontological
nursing.
2. Identify standards used in gerontological nursing practice.
3. List principles guiding gerontological nursing practice.
4. Discuss major roles for gerontological nurses.
5. Discuss future challenges for gerontological nursing.
6. Describe activities that contribute to self-care for gerontological
nurses.
TERMS TO KNOW
Competencyhaving skill, knowledge, and ability to do something
according to a standard
Evidence-based practiceusing research and scientific information to
guide actions
Geriatric nursingnursing care of sick older adults
Gerontological nursingnursing practice that promotes wellness and
highest quality of life for aging individuals
Standarddesired, evidence-based expectations of care that serve as a
model against which practice can be judged
The specialty of gerontological nursing was not always a popular or well-

respected area of practice. However, over the past few decades, the
specialty has experienced profound growth and has benefited from societal
recognition of the importance of the older segment of the population.
Nurses have many opportunities to play significant roles in the care of the
aging population today and to shape the future of gerontological nursing.
DEVELOPMENT OF
Nurses, long interested in the care of older adults, seem to have assumed
more responsibility than other professional disciplines for this segment of
the population. In 1904, the American Journal of Nursing printed the first
nursing article on the care of the aged, presenting many principles that
continue to guide gerontological nursing practice today (Bishop, 1904):
“You must not treat a young child as you would a grown person, nor must
you treat an old person as you would one in the prime of life.” Interestingly,
this same journal featured an article entitled “The Old Nurse,” which
emphasized the value of the aging nurse’s years of experience (DeWitt,
1904).
After the Federal Old Age Insurance Law (better known as Social
Security) was passed in 1935, many older persons had an alternative to
almshouses and could independently purchase room and board. Because
many of the homes that offered these services for older persons were
operated by women who called themselves nurses, such residences later
became known as nursing homes.
For many years, care of older adults was an unpopular branch of
nursing practice. Geriatric nurses—those nurses who care for ill older adults
—were thought to be somewhat inferior in capabilities, neither good
enough for acute care settings nor ready to retire. Geriatric facilities may
have further discouraged many competent nurses from working in these
settings by paying low salaries. Little existed to counter the negativism in
educational programs, where experiences with older persons were
inadequate in both quantity and quality and attention focused on the sick
rather than the well, who were more representative of the older population.
Although nurses were among the few professionals involved with older
adults, gerontology was missing from most nursing curriculums until
recently.
Frustration over the lack of value placed on geriatric nursing led to an
appeal to the American Nurses Association (ANA) for assistance in
promoting the status of this area of practice. After years of study, in 1961,
the ANA recommended that a specialty group for geriatric nurses be
formed. In 1962, the ANA’s Conference Group on Geriatric Nursing
Practice held its first national meeting. This group became the Division of
Geriatric Nursing in 1966, gaining full recognition as a nursing specialty.
An important contribution by this group was the development in 1969 of
Standards for Geriatric Nursing Practice, first published in 1970.
Certification of nurses for excellence in geriatric nursing practice followed,
with the first 74 nurses achieving this recognition in 1975. The birth of the
Journal of Gerontological Nursing, the first professional journal to meet the
specific needs and interests of gerontological nurses, also occurred in 1975.
Through the 1970s, nurses became increasingly aware of their role in
promoting a healthy aging experience for all individuals and ensuring the
wellness of older adults. As a result, they expressed interest in changing the
name of the specialty from geriatric to gerontological nursing to reflect a
broader scope than the care of the ill aged. In 1976, the Geriatric Nursing
Division became the Gerontological Nursing Division. Box 6-1 lists
landmarks in the development and growth of gerontological nursing.
BOX 6-1 Landmarks in the Growth of

KEY CONCEPT
Gerontological nursing involves the care of aging people and emphasizes
the promotion of the highest possible quality of life and wellness
throughout the life span. Geriatric nursing focuses on the care of sick
older persons.
In the past few decades, the specialty of gerontological nursing has

experienced profound growth. Whereas only 32 articles on the topic of the
nursing care of older adults were listed in the Cumulative Index to Nursing
Literature in 1956, and only twice that number appeared a decade later, the
number of articles published has grown considerably since. Gerontological
nursing texts grew from a few in the 1960s to dozens currently, and the
quantity and quality of this literature have been rising as well. Growing
numbers of nursing schools are including gerontological nursing courses in
their undergraduate programs and offering advanced degrees with a major
in this area. Certification offers a means by which the nurse’s knowledge
and competencies are validated through a professional nursing organization.
Registered nurses can receive certification as a generalist in gerontological
nursing with an associate’s or bachelor’s degree and 2 years of experience
in the specialty or advanced certification as a clinical nurse specialist in
gerontological nursing or gerontological nurse practitioner with additional
education and experience. (For information on certification, see the
Resource listing for the American Nurses’ Credentialing Center at the end
of this chapter.) Nursing administration in long-term care, geropsychiatric
nursing, geriatric rehabilitation, and other areas of subspecialization has
evolved; many nursing specialty associations have developed position
papers related to the integration of geriatric nursing into their unique
specialty practice (these often are posted on the association Web sites). The
Hartford Institute for Geriatric Nursing, established in the 1990s, has
significantly contributed to the advancement of the specialty by identifying
and developing best practices and facilitating the implementation of these
practices (for more information, visit http://www.hartfordign.org). In 2003,
the Hartford Institute for Geriatric Nursing collaborated with the American
Academy of Nursing and the American Association of Colleges of Nursing
to develop the Hartford Geriatric Nursing Initiative that has significantly
contributed to the growth of evidence-based practice in the specialty,
including publishing the Recommended Baccalaureate Competencies and
Curricular Guidelines for the Nursing Care of Older Adults in 2010.
Gerontological nursing has indeed advanced rapidly, and all indications are
that this growth will continue.
Along with the growth of the specialty, there has been a heightened
awareness of the complexity of gerontological nursing. Older people exhibit
great diversity in terms of health status, cultural background, lifestyle,
living arrangement, socioeconomic status, and other variables. Most have
chronic conditions that uniquely affect acute illnesses, reactions to
treatments, and quality of life. Symptoms of illness can be atypical.
Multiple health conditions can coexist and muddle the ability to chart the
course of a single disease or identify the underlying cause of symptoms.
The conditions that older adults experience can cut across many clinical
specialties, thereby challenging gerontological nurses to have a broad
knowledge base. The risk of complications is high. Other factors, such as
limited finances or social isolation, affect the state of health and well-being.
Also, the elective status of geriatrics in many medical and nursing schools
can limit the pool of colleagues who are knowledgeable about the unique
aspects of caring for older adults.
CORE ELEMENTS OF
PRACTICE
With the formalization and growth of the gerontological nursing specialty,
nurses and nursing organizations have developed informal and formal
guidelines for clinical practice. Some of these core elements include
evidence-based practice and standards and principles of gerontological
nursing.
There was a time when nursing care was guided more by trial and error than
sound research and knowledge. Fortunately, that has changed, and nursing
now follows a systematic approach that uses existing research for clinical
decision-making—a process known as evidence-based practice. Testing,
evaluating, and using research findings in the nursing care of older adults
are of such importance that it is among the ANA Standards of Professional
Gerontological Nursing Performance.
Evidence-based practice relies on the synthesis and analysis of available
information from research. Among the more popular ways to report this
information are the meta-analysis and cost-analysis. Meta-analysis is a
process of analyzing and compiling the results of published research studies
on a specific topic. This process combines the results of many small studies
to allow more significant conclusions to be made. With cost-analysis
reporting, cost-related data are gathered on outcomes to make comparisons.
Performance also can be compared with best practices or industry averages
through a process of benchmarking. For instance, the rate of pressure ulcers
in one facility may be compared with another facility that has similar
characteristics. The data can be used to stimulate improvements.
KEY CONCEPT
Best practices are evidence based and are built on the expertise of the
nurse.
Standards
Professional nursing practice is guided by standards. Standards reflect the
level and expectations of care that are desired and serve as a model against
which practice can be judged. Thus, standards serve to both guide and
evaluate nursing practice.
Standards arise from a variety of sources. State and federal regulations
outline minimum standards of practice for various health care workers (e.g.,
nurse practice acts) and agencies (e.g., nursing homes). The Joint
Commission has developed standards for various clinical settings that strive
to describe the maximum attainable performance levels. The American
Nurses Association Scope and Standards of Gerontological Nursing
Practice are the only standards developed by and for gerontological nurses;
they can be obtained from the American Nurses Association,
https://www.nursingworld.org/nurses-books. Nurses must regularly evaluate
their actual practices against all standards governing their practice areas to
ensure their actions reflect the highest quality care possible.
Competencies
Nurses who work with older adults need to have competencies specific to
gerontological nursing to promote the highest possible quality of care to
older adults. Although they can vary based on educational preparation, level
of practice, and practice setting, some basic competencies of the
gerontological nurse include the ability to:
Differentiate normal from abnormal findings in the older adult

Assess the older adult’s physical, emotional, mental, social, and
spiritual status and function
Engage the older adult in all aspects of care to the maximum extent
possible
Provide information and education on a level and in a language
appropriate for the individual
Individualize care planning and implementation of the plan
Identify and reduce risks
Empower the older adult to exercise maximum decision-making
Identify and respect preferences arising from the older adult’s culture,
language, race, gender, sexual preference, lifestyle, experiences, and
roles
Assist the older adult in evaluating, deciding, locating, and
transitioning to environments that fulfill living and care needs
Advocate for and protect the rights of the older person
Facilitate discussion of and honor advance directives
To maintain and improve competencies, nurses need to stay abreast of

new research, resources, and best practices. This is a personal responsibility
of the professional nurse.
Principles
Scientific data regarding theories, life adjustments, normal aging, and
pathophysiology of aging are combined with selected information from
psychology, sociology, biology, and other physical and social sciences (Fig.
6-1) to develop nursing principles. Nursing principles are those proven facts
or widely accepted theories that guide nursing actions. Professional nurses
are responsible for using these principles as the foundation for nursing
practice and ensuring through educational and managerial means that other
caregivers use a sound knowledge base.
FIGURE 6-1 Information system of the gerontological
nurse.
CONSIDER THIS CASE

Nurse Haley is a new graduate who is
employed on a coronary care unit of an acute hospital. In her short time on
the unit, she has noticed that the nurses who have worked on the unit for
many years show certain tendencies when caring for patients over age 65.
For example, they address comments and questions to these patients’
children rather than directly to the patients, address them in a child-like
manner, tend not to inquire about their lifestyles and preferences, assume
they have sedate lives, and omit the discussion of topics that they do
discuss with younger patients, such as sexual activity, exercise, resuming
work activities, and using alternative and complementary therapies. Nurse
Haley feels her coworkers’ behaviors fail to respect the individuality and
rights of older patients and could jeopardize the quality of care they are
afforded.
THINK CRITICALLY
1. What gerontological nursing competencies seem to be absent from the
practice of the nurses Nurse Haley describes?
2. What are some of the factors that could have contributed to the
nurses’ behaviors?
3. How should Nurse Haley address the problems she observes to
promote good gerontological nursing practice?
In addition to the basic principles that direct the delivery of care to
persons in general, specific and unique principles guide care for individuals
of certain age groups or those who possess particular health problems.
Some of the principles guiding gerontological nursing practice are listed in
Box 6-2 and are discussed below.
BOX 6-2 Principles of Gerontological Nursing

Practice
Aging is a natural process common to all living organisms.
Various factors influence the aging process.
Unique data and knowledge are used in applying the nursing
process to the older population.
Older adults share similar self-care and human needs with all other
human beings.
Gerontological nursing strives to help older adults achieve
wholeness by reaching optimum levels of physical, psychological,
social, and spiritual health.
Aging: A Natural Process

Every living organism begins aging from the time of conception. The
process of maturing or aging helps the individual achieve the level of
cellular, organ, and system function necessary for the accomplishment of
life tasks. Constantly and continuously, every cell of every organism ages.
Despite the normality and naturalness of this experience, many people
approach aging as though it were a pathologic experience. For example,
commonly heard comments associate aging with:
“Looking gray and wrinkled”

“Losing one’s intellectual function”
“Becoming sick and frail”
“Obtaining little satisfaction from life”
“Returning to child-like behavior”
“Being useless”
These are hardly valid descriptions of the outcomes of aging for most
people. Aging is not a crippling disease; even with limitations that could be
imposed by some of the pathologies of late life, opportunities for
usefulness, fulfillment, and joy are readily present. A realistic
understanding of the aging process can promote a positive attitude toward
old age.
Factors Influencing the Aging Process

Heredity, nutrition, health status, life experiences, environment, activity,
and stress produce unique effects in each individual. Among the variety of
factors either known or hypothesized to affect the usual pattern of aging,
inherited factors are believed by some researchers to determine the rate of
aging. Malnourishment can hasten the ill effects of the aging process, as can
exposure to environmental toxins, diseases, and stress. In contrast, mental,
physical, and social activity can reduce the rate and degree of declining
function with age. These factors are examined in more detail in Chapter 2.
Every person ages in an individualized manner, although some general
characteristics are evident among most people in a given age category. Just
as one would not assume that all 30-year-old people are identical but would
evaluate, approach, and communicate with each person in an individualized
manner, nurses must recognize that no two persons 60, 70, or 80 years of
age are alike. Nurses must understand the multitude of factors that influence
the aging process and recognize the unique outcomes for each individual.
The Nursing Process Framework

Scientific data related to normal aging and the unique psychological,
biological, social, and spiritual characteristics of the older person must be
integrated with a general knowledge of nursing. The nursing process
provides a systematic approach to the delivery of nursing care and
integrates a wide range of knowledge and skills. The scope of nursing
includes more than following a medical order or performing an isolated
task; the nursing process involves a holistic approach to individuals and the
care they require. The unique physiologic, psychological, social, and
spiritual challenges of older adults are considered in every phase of the
nursing process.
Common Needs
Core needs that promote health and optimum quality of life for all patients
are:
Physiological balance: respiration, circulation, nutrition, hydration,

elimination, movement, rest, comfort, immunity, and risk reduction
Connection: familial, relational, societal, cultural, environmental,
spiritual, and self
Gratification: purpose, pleasure, and dignity
Through self-care practices, people usually perform activities

independently and voluntarily to meet these life requirements. When an
unusual circumstance interferes with an individual’s ability to meet these
demands, nursing intervention could be warranted. The requirements for
these needs and specific problems that older persons may experience in
fulfilling them are discussed in Units III through V.
Optimal Health and Wholeness

One can view aging as the process of realizing one’s humanness,
wholeness, and unique identity in an ever-changing world. In late life,
people achieve a sense of personhood that allows them to demonstrate
individuality and move toward self-actualization. By doing so, they are able
to experience harmony with their inner and external environment, realize
their self-worth, enjoy full and deep social relationships, achieve a sense of
purpose, and develop the many facets of their being. Gerontological nurses
play an important role in promoting health and helping people achieve
wholeness. Within the framework of the self-care theory, nursing actions
toward this goal are:
Strengthening the individual’s self-care capacity

Eliminating or minimizing self-care limitations
Providing direct services by acting for, doing for, or assisting the
individual when demands cannot be met independently
The thread woven throughout the above nursing actions is the

promotion of maximum independence. Although it may be more time
consuming and difficult, allowing older persons to do as much for
themselves as possible produces many positive outcomes for their
biopsychosocial health.
POINT TO PONDER
What self-care practices are routine parts of your life? What is lacking?
GERONTOLOGICAL NURSING ROLES

In their activities with older adults, nurses function in a variety of roles,
most of which fall under the categories of healer, caregiver, educator,
advocate, and innovator (Fig. 6-2).
FIGURE 6-2 Gerontological nursing roles.
Healer
Early nursing practice was based on the Christian concept of the
intertwining of the flesh and spirit. In the mid-1800s, nursing’s role as a
healing art was recognized; this is apparent through Florence Nightingale’s
writings that nursing “puts the patient in the best condition for nature to act
upon him” (Nightingale, 1860). 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. However, the revival of the holistic approach to
health care has enabled nurses to again recognize the interdependency of
body, mind, and spirit in health and healing.
Nursing plays a significant role in helping individuals stay well,
overcome or cope with disease, restore function, find meaning and purpose
in life, and mobilize internal and external resources. In the healer role, the
gerontological nurse recognizes that most human beings value health, are
responsible and active participants in their health maintenance and illness
management, and desire harmony and wholeness with their environment. A
holistic approach is essential, recognizing that older individuals must be
viewed in the context of their biological, emotional, social, cultural, and
spiritual elements. (Information on holistic nursing can be obtained from
the American Holistic Nurses’ Association, listed under Resources at the
end of this chapter.)
POINT TO PONDER
Henri Nouwen (1990) spoke of the “wounded healer” who uses his or
her own problems or wounds as a means to assist in the healing of
others. What life experiences or “wounds” do you possess that enable
you to assist others in their healing journeys?

For healing to be a dynamic process, nurses need to identify their own
weaknesses, vulnerabilities, and need for continued self-healing. This
belief is consistent with the concept of the wounded healer and suggests
that by recognizing the wounds of all human beings, including themselves,
nurses can provide services within a loving, compassionate framework.
Caregiver
The major role played by nurses is that of a caregiver. In this role,
gerontological nurses use gerontological theory in the conscientious
application of the nursing process to the care of older adults. Inherent in this
role is the active participation of older adults and their significant others
and promotion of the highest degree of self-care. This is especially
significant in that older adults who are ill and disabled are at risk for having
decisions made and actions taken for them—in the interest of “providing
care,” “efficiency,” and “best interest”—that rob them of their existing
independence.
Although the body of knowledge of geriatrics and gerontological care
has grown considerably, many practitioners lack this information.
Gerontological nurses are challenged to ensure that the care of older adults
is based on sound knowledge that reflects the unique characteristics, needs,
and responses of older persons by disseminating gerontological principles
and practices. Nurses working in this specialty area are challenged to gain
the knowledge and skills that will enable them to meet the unique needs of
older adults and to assure evidence-based practices are utilized.
Educator
Gerontological nurses must be prepared to take advantage of formal and
informal opportunities to share knowledge and skills related to the care of
older adults. This education extends beyond professionals to the general
public. Areas in which gerontological nurses can educate others include
normal aging, pathophysiology, geriatric pharmacology, health promotion,
and available resources. With the diversity and complexities of health
insurance plans, an important area for consumer education is teaching older
adults how to interpret and compare various plans to enable them to make
informed decisions. Essential to the educator role is effective
communication involving listening, interacting, clarifying, coaching,
validating, and evaluating.
The nurse’s educator role also surfaces during routine nurse–patient
interactions. The nurse educates the patient to address knowledge deficits
identified during the assessment process. New medications, treatments, and
choices create the need for teaching to assure the patient has the knowledge
and skill to competently make decisions and engage in care. Box 6-3
outlines some of the principles of adult learning and some of the barriers to
learning.
BOX 6-3 Teaching Older Adults

When teaching older adults:
Assess knowledge deficits, readiness to learn, and obstacles that

could interfere with the learning process.
Organize the material prior to the teaching experience.
Plan strategies to actively engage them in the learning process.
Assure the environment is conducive to learning (e.g., comfortable
room temperature, noise control, avoidance of glare, and lack of
distractions and interruptions).
Be sensitive to vision and hearing deficits that are present.
Speak on a level and in a language that is understandable.
Avoid medical jargon.
Use several different teaching methods to supplement verbal
presentation (e.g., videos, demonstration, PowerPoint slides,
pamphlets, and fact sheets).
Provide written material to complement verbal instruction; as blues
and greens are difficult colors for older eyes, avoid using blue print
on green paper.
Summarize what has been taught and recognize knowledge gains.
Be aware of potential barriers to learning:
Stress
Sensory deficits
Limited educational or intellectual abilities
Language barriers
Emotional state
Pain, fatigue, and other symptoms
Unmet physiological needs
Attitudes or beliefs held about topic
Prior experience with issue
Feelings of helplessness and hopelessness
Advocate
The gerontological nurse can function as an advocate in several ways. First
and foremost, advocacy for individual clients is essential and can include
aiding older adults in asserting their rights and obtaining required services.
In addition, nurses can advocate to facilitate a community’s or other group’s
efforts to effect change and achieve benefits for older adults and to promote
gerontological nursing, including new and expanded roles of nurses in this
specialty.
Innovator
Gerontological nursing continues to be an evolving specialty; therefore,
nurses have opportunities to develop new technologies and different
modalities of care delivery. As an innovator, the gerontological nurse
assumes an inquisitive style, making conscious decisions and efforts to
experiment for an end result of improved gerontological practice. This
requires the nurse to be willing to think “out of the box” and take risks
associated with traveling down new roads, transforming visions into reality.
These roles can be actualized in a variety of practice settings, discussed
in Chapter 10, and offer opportunities for gerontological nurses to
demonstrate significant creativity and leadership.
ADVANCED PRACTICE NURSING

ROLES
To competently and effectively care for the clinical complexities of older
adults, nurses need preparation in the unique principles and best practices of
geriatric care. This requires a broad knowledge base, capacity for
independent practice and leadership, and complex clinical problem-solving
ability that is possible by nurses prepared for advanced practice roles.
Advance practice roles include geriatric nurse practitioners, geriatric nurse
clinical specialists, and geropsychiatric nurse clinicians. Most of these roles
require the completion of a master’s degree at a minimum.
There is strong evidence that nurses in advanced practice roles make a
significant difference to the care of older adults. Gerontological nurse
practitioners and clinical nurse specialists have been shown to improve the
quality and reduce the cost of care for older persons in a variety of settings,
including hospitals, nursing homes, and ambulatory care. The clear positive
impact on the health and well-being of older adults should encourage
gerontological nurses to pursue these types of advanced practice roles and
to encourage the employment of these advanced practitioners in their
clinical settings.
SELF-CARE AND NURTURING

The depth and intensity of the nurse–patient relationship that results when
nurses function as healers creates a highly therapeutic and meaningful
experience that reflects the essence of professional nursing. Although the
formal educational preparation of nurses offers the foundation for this level
of healing relationship, the nurse’s self-care influences the potential height
and depth that can be realized. Some strategies for self-care include
following positive health care practices and strengthening and building
connections.

Like all human beings, nurses have basic physiological needs. Although
most nurses are familiar with the requirements necessary to meet each of
these needs (e.g., proper diet, adequate rest, exercise, etc.), they may not be
applying this knowledge to their personal lives. Self-care can suffer as a
result.
A periodic “checkup” of physical status can prove useful in disclosing
problems that could not only minimize the ability to provide optimal
services to patients but also threaten personal health and well-being. It
could prove useful for nurses to allocate a few hours, find a quiet place, and
critically review their health status.
After identifying problems, nurses can plan realistic actions to improve
health. Writing the actions on an index card and placing that card in an area
that is regularly seen (e.g., dresser, desk, or dashboard) can provide regular
reminders of intended corrective actions.
KEY CONCEPT
Efforts to improve self-care practices can be facilitated by partnering
with a “buddy” who can offer support, encouragement, and a means for
accountability.
Strengthening and Building Connections

Humans are relational beings who are intended to live in a community with
others. The richness of nurses’ connections in their personal lives provides
fertile soil to grow meaningful connections with patients. Yet, as basic and
common as relationships can be, they can be quite challenging. Among the
major challenges, nurses may face are finding and protecting the time and
energy to connect with others in meaningful ways. Like many other
professionals in helping professions, nurses may find that the physical,
emotional, and mental energies exerted in a typical workday leave little in
reserve to invest in nurturing relationships with friends and family. The
reactions to work-related stress can be displaced to significant others,
thereby interfering with positive personal relationships. To compound the
problem, concern for patients’ welfare or employer pressure can lead to
excessive overtime work, leaving precious little time and energy for nurses
to do anything more in their off hours than attend to basics. Strained
personal connections are the weeds of untended relationship gardens.
POINT TO PONDER
List five significant individuals in your life. Reflect on the amount of
quality time you have with each of them and determine if this time is
conducive to a strong relationship.
Relationships
The allocation of time and energy requires the same planning as the
allocation of any finite resource. Ignoring this reality risks suffering the
consequences of poor relationships. Recognizing that there always will be
activities to vie for time and energy, nurses need to take control and develop
practices that reflect the value of personal relationships. This can involve
limiting the amount of overtime worked to no more than “x” hours each
week, dedicating every Thursday evening to dining out with the family or
blocking out Sunday afternoons to visit or telephone friends. Expressing
intentions through understood “personal policies” (e.g., informing a
supervisor that you will work no more than one double shift per month) and
committing time on your calendar (e.g., blocking off every Sunday
afternoon for time with friends) increase the likelihood that significant
relationships will receive the attention they require.
Spirituality
Time and energy also must be protected to afford ample time for connecting
with the nonphysical power that offers inspiration, gives life meaning, and
implies something greater than one’s self. For some, this can be God, for
others, a nondescript higher power, yet for others, a connection with nature
and all living things. The spiritual grounding resulting from this connection
enables nurses to better understand and serve the spiritual needs of patients.
Nurses can enhance spiritual connection through prayer, fasting, attending
church or temple, engaging in Bible or other holy book studies, taking
periodic retreats, and practicing days of solitude and silence.
Connection With Self

Connection with self is essential to nurses’ self-care, and this begins with a
realistic self-appraisal. Examples of strategies to facilitate this process
include sharing life stories, journaling, meditating, and taking retreats.
POINT TO PONDER
What does it mean to you to be connected to self?
Sharing Life Stories

Every adult has a unique and rich storehouse of experiences that have been
cemented into the life in which he or she dwells. Oral sharing of life stories
with others helps people gain self-insight and puts experiences into a
perspective that affords meaning. As people share stories, they begin to see
that their lives are not the only ones that have been less than ideal and
sprinkled with pain or have unfolded in unintended ways. They also are
able to reflect on positive experiences that influenced their lives. Writing
one’s life story is a powerful means of reflection that affords a permanent
record that can be revisited and reconsidered as one gains deeper wisdom
about self and others. The process of sharing life stories can be particularly
meaningful for gerontological nurses in their work with older adults who
often have interesting life histories that they are eager to share—and that
frequently can offer rich life lessons.
COMMUNICATION TIP
To encourage older adults to write their life stories, discuss the value
that this record could have for younger family members and offer
specific suggestions for how their stories could be structured, such as
by:
Significant events during each decade of life

Descriptions of major events, people, or issues such as their
parents, immigration to this country, childhood friends,
neighborhood in which they grew up, school experiences, firsts
(e.g., date, car, job, home), work experiences, adult friends,
hobbies, accomplishments, disappointments, things they felt
positive about, and major societal changes they witnessed
Emphasize that it isn’t the writing skill that matters but the gift of
documented memories that will be shared with future generations.
Journaling
Writing personal notes in a journal or diary can facilitate reflection on one’s
life. These writings differ from written life stories in that they record
current activities and thoughts rather than past ones. An honest written
account of feelings, thoughts, conflicts, and behaviors can help people learn
about themselves and work through issues.
Meditating
The ancient practice of meditation has helped people sort out thoughts and
gain clarity of direction for ages. Many nurses find meditation challenging
because the nature of their work consists of doing—and multitask doing, at
that! However, periods of being still enable nurses to offer an optimum
healing presence to their patients.
There are several techniques that can be used for meditating;
individuals vary in their preference for the different forms of meditation.
Some people may focus on a word or prayer, whereas others may choose to
have no intentional thought and to be open to whatever thoughts drift into
their minds. Essential elements to any form of meditation are a quiet
environment, comfortable position, and calm and passive attitude. The
physiological responses associated with the deep relaxation achieved during
meditation have many health benefits (e.g., improved immunity, reduced
blood pressure, and increased peripheral blood flow). Often, issues a person
has been struggling with can be clarified through meditation.
Taking Retreats
To many nurses, taking a few days off “to do nothing” seems like a luxury
that cannot be afforded. After all, there is the house to get in order,
shopping that must be done, and overtime that can be worked to gather a
few extra dollars for vacation. In addition to the tasks that compete for
attention and time, there may be the mental script that insidiously gives the
message that it is selfish to forfeit tangibly productive activities to spend
time thinking, reflecting, and experiencing. Yet, unless nurses want their
interactions with patients to be solely mechanical (i.e., task oriented), they
must treat themselves as more than machines. Their bodies, minds, and
spirits must be restored and refreshed periodically to offer holistic care—
and retreats offer an ideal means to achieve that.
A retreat is a withdrawal from normal activities. It can be structured or
unstructured, guided by a leader or self-directed, and taken with a group or
alone. Although retreats are offered in exotic locations that offer lavish
provisions, they need not be luxurious or expensive. Whatever the location
or structure, key elements of the retreat experience include a respite from
routine responsibilities; freedom from distractions (telephones, e-mails,
children, and doorbells); no one to care for and worry about other than self;
and a quiet place. The charge that a retreat provides to one’s physical,
emotional, and spiritual batteries will more than compensate for the tasks
that were postponed.
KEY CONCEPT
When nurses have strong, grounded connections to themselves, they are
in a better position to have meaningful connections with patients.
Committing to a Dynamic Process

Self-care is an ongoing process that demands active attention. However,
knowing the actions that support self-care is only the beginning.
Committing to engaging in one’s self-care completes the picture. This may
mean that limits are set on the amount of overtime worked to adhere to an
exercise schedule or that one is willing to face the uncomfortable feelings
experienced during the process of reflecting on less than pleasant life
experiences. Sacrifices, unpopular decisions, and discomfort can result
when one chooses to “work on oneself.” Yet, it is this inner work that
contributes to nurses being effective healers and models of healthy aging
practices.
THE FUTURE OF GERONTOLOGICAL

NURSING
Historically, nurses were the major caregivers to older adults. Going
forward, gerontological nurses must strive to protect and advocate for both
the care of older adults and the specialty of gerontological nursing.
Tremendous strides have been made already. Dynamic professionals are
selecting gerontological nursing as a specialty that offers a multitude of
opportunities to use a wide range of knowledge and skills and one that
presents many challenges that can be independently addressed within the
realm of nursing practice. Excellent research for and by nurses is growing
to provide a strong scientific foundation for practice. Increasing numbers of
nursing schools are adding specialization in gerontological nursing. New
opportunities for gerontological nurses to develop practice models are
emerging in acute hospitals, assisted-living settings, health maintenance
organizations, life-care communities, adult day treatment centers, and other
settings (Fig. 6-3). The future of gerontological nursing appears dynamic
and exciting. Nevertheless, more challenges exist.
FIGURE 6-3 The specialty of gerontological nursing
offers multiple opportunities to use a wide range of
knowledge and skills in a variety of settings.

Considerable knowledge has been gained through research that can guide
practice that is based on evidence rather than assumption; the body of
knowledge continuously grows and changes. Practices that were routine in
years past may have since been discovered to be ineffective or even
harmful. This challenges nurses in keeping abreast of and utilizing
evidence-based practices.
Gerontological nurses can access literature upon which evidence-based
practice can be obtained from several sources. The Cochrane Collaboration
(www.cochrane.org) publishes Cochrane Reviews, systematic assessments
of research that meet the highest standard in evidence-based practice.
Among the collaboration’s valuable resources are links to databases
offering online access to medical evidence from other sites. The Agency for
Healthcare Research and Quality (www.ahrq.gov) offers knowledge, data,
and tools to enhance the quality of care. The Hartford Institute for Geriatric
Nursing (www.hartfordign.org) offers many evidence-based resources to
guide geriatric nursing practice. In addition, geriatric and gerontological
journals and publications of professional associations provide reports of
recent research.
The gerontological nurse should assure that when new policies and
procedures are being developed in the workplace, they are based on
evidence. This may require the nurse to conduct a literature search and
summarize and present findings to other members of the team. Bridging
research to the practice setting is an important function of the
gerontological nurse.
Advance Research
The growing complexity of and demand for gerontological nursing services
is exciting and challenging but is accompanied by the need for a strong
knowledge base on which these services can be built. There is no room for
the trial and error that flavored nursing actions in the past; older adults’
delicately balanced health status, increased consumer expectations, ever-
present risk of litigation, and the requisites of professionalism demand
scientific foundations for nursing practice. Fine nursing research is being
conducted on a variety of issues, and gerontological nurses must encourage
and support these efforts through various actions.
One way for nurses to advance research is to network with nurse
researchers. Researchers can be important resources. Combining their
research skills with the abilities of those in practice settings can help to
solve clinical problems. Local academic institutions, teaching hospitals, and
nursing homes may be conducting research that can be relevant to various
gerontological settings or in which a service agency can participate.
Nurses can also help to support research efforts in a variety of ways. As
funding is sought for research projects, nurses can write letters of support
and testimony to help funding agencies understand the full benefit of the
research effort. Regular contact with leaders who influence the allocation of
funds can provide opportunities to educate these persons on the value of
supporting research. No less significant to the support of research efforts is
the assurance that protocols be followed, because the efforts of researchers
can be facilitated or thwarted by colleagues in clinical settings.
Finally, nurses must keep abreast of new findings. Gerontological
nursing knowledge is continuously expanding, disproving past beliefs and
offering new insights. Nurses can engage in independent study, formal
courses, and continuing education programs to keep current. Equally
important to acquiring knowledge is implementing evidence-based practice
to improve the care of older adults. Older adults’ delicately balanced health
status and high risk of complications, along with rising consumer
expectations and a highly litigious society, reinforce the importance of
evidence-based practice.

In the United States, conventional medicine, with an emphasis on the
diagnosis and treatment of diseases, has set the tone for health care practice.
Current managed care and reimbursement priorities reinforce the medical
model and disease-focused care. Unfortunately, the care of medical
conditions is just one aspect of the services older adults need to be healthy
and experience a high quality of life. In fact, older persons’ wellness
practices; adjustments to life changes; sense of purpose, hopefulness, joy,
connections to others; and ability to manage stress can be equally if not
more significant to their health and quality of life than medical care.
Nurses must ensure that gerontological care is holistic, meaning that the
physical, emotional, social, and spiritual facets of individuals are
considered (see Chapter 7). This implies that nurses not only practice in a
holistic manner themselves but also advocate for other disciplines to do so.
Alternative and complementary therapies play a role in holistic care.
These therapies tend to be more comforting, safe, and less invasive than
conventional treatments and empower older adults and their caregivers in
self-care. Many people who use these therapies report positive experiences
with their alternative therapists, who frequently spend more time getting to
understand and address the needs of the total person than do staff in the
typical medical office or hospital. However, the use of alternative therapies
does not equate with holistic care. An alternative therapist with tunnel
vision, believing that every malady can be corrected with the one modality
he or she practices and excluding effective conventional treatments, is no
different from the physician who prescribes an analgesic but does not
consider imagery, massage, relaxation exercises, and other nonconventional
forms of pain relief. Integrating the best of conventional and
alternative/complementary therapy supports holistic care.
Part of a holistic approach to care includes care of the caregivers as
well. Professional and family caregivers who are in poor health, struggling
with psychosocial issues, feeling spiritually empty and disconnected, or
managing stress poorly need to heal themselves before they can be effective
caregivers. Nurses can assist these caregivers in identifying their needs and
finding the help needed for their healing.
POINT TO PONDER
Many nurses are in poor physical condition, smoke, regularly eat junk
foods, take little time for themselves, and demonstrate other unhealthy
habits. What do you think are some of the reasons for this? What can be
done to improve nurses’ health habits?
Educate Caregivers
Be it the nursing director, a family member who cares for an older relative,
a health aide who has more frequent contact with the patient than the
professional nurse, or the physician who only occasionally has an older
person in the caseload, caregivers at every level require competency in
providing services to the older population. Gerontological nurses can
influence the education of caregivers by:
Helping nursing schools identify relevant issues for inclusion in the

curricula
Participating in the classroom and field experiences of students
Evaluating educational deficits of personnel and planning educational
experiences to eliminate deficits
Promoting interdisciplinary team conferences
Attending and participating in continuing education programs
Reading current nursing literature and sharing information with
colleagues
Serving as a role model by demonstrating current practices
With increasing numbers of family members providing more complex

care in the home setting than ever before, it is essential that the education of
this group not be overlooked. It should not be assumed that because the
family has had contact with other providers or has been providing care they
are knowledgeable in correct care techniques. The nurse must periodically
evaluate and reinforce the family’s knowledge and skills.
Develop New Roles

As gerontological subspecialties and settings for care grow, so will the
opportunities for nurses to carve new roles for themselves. Nurses can
demonstrate creativity and leadership as they break from traditional roles
and settings and develop new models of practice, which may include the
following:
Geropsychiatric nurse specialist in the continuing care retirement

community setting
Independent case manager for community-based chronically ill
patients
Columnist for local newspaper on issues pertaining to health and aging
Owner or director of mature women’s health care center, geriatric day
care program, respite agency, or caregiver training center
Preretirement counselor and educator for private industry
Faith community nurse
Consultant, educator, and case manager for geriatric surgical patients
This list only begins to describe opportunities awaiting gerontological

nurses. Many opportunities exist for nurses to develop new practice models
in gerontological care. It will be important for gerontological nurses to
identify nontraditional roles, approach them creatively, test innovative
practice models, and share their successes and failures with colleagues to
aid them in their development of new roles. Nurses must recognize that
their biopsychosocial sciences knowledge, clinical competencies, and
human relations skills give them a strong competitive edge over other
disciplines in affecting a wide range of services.
POINT TO PONDER
Based on changes in the health care system and society at large, what
unique services could gerontological nurses offer in the future within
your community?

The growing number of older adults is placing increasing demands for
diverse health care services than ever before. At the same time, third-party
insurers are trying to control the constantly escalating cost of services.
Earlier hospital discharges, limited home health visits, increased complexity
of nursing home residents, and greater out-of-pocket payment for services
by patients demonstrate some of the effects of changes in reimbursement
policy. There is concern that, as a result of these changes, patients are
discharged from hospitals prematurely and suffer greater adverse
consequences, nursing homes are confronting residents with complex
problems for whom they are not adequately prepared or staffed, families are
being strained by considerable caregiving burdens, and patients are being
deprived of needed but unaffordable services.

Changes in reimbursement practices result in the earlier hospital discharge
of patients with high acuity level care needs. The limited reimbursement
for nursing home and home health care services may not provide the
resources to adequately provide the type of care required by these
individuals.
Such changes are disconcerting and may cause nurses to feel

overwhelmed, frustrated, or dissatisfied. Unfortunately, more cost cutting is
likely to occur. Rather than experience burnout or consider a change of
occupation, nurses should become involved in cost-containment efforts so
that a balance between quality services and budgetary concerns can be
achieved. Efforts toward this goal can include the following:
Test creative staffing patterns. Perhaps six nurses can be more

productive than three nurses and three unlicensed caregivers. Or,
perhaps some of the high nonproductive time costs associated with
unlicensed personnel are related to poor hiring and supervision
practices; improved management techniques may increase the cost-
effectiveness of these workers.
Use lay caregivers. Neighbors assisting each other, a family member
rooming-in during hospitalizations, and other methods to increase the
resources available for service provision can be explored.
Abolish unnecessary practices. Why must nurses spend time
administering medications to patients who have successfully
administered them before admission and who will continue to
administer them after discharge, take vital signs every 4 hours on
patients who have shown no abnormalities, bathe all patients on the
same schedule regardless of skin condition or state of cleanliness, or
rewrite assessments and care plans at specified intervals regardless of a
patient’s changes or stability? Often regulations and policies are
developed under the assumption that, without them, vital signs would
never be taken, baths would not be given, and other facets of care
would not be completed. Perhaps the time has come for nurses to
aggressively convince others that they have the professional judgment
to determine the need for and frequency of assessment, care planning,
and care delivery.
Ensure safe care. The implementation of cost-containment efforts
should be accompanied by concurrent studies of its impact on rates of
complications, readmissions, incidents, consumer satisfaction, and
staff turnover, absenteeism, and morale. Specific numbers and
documented cases carry more weight than broad criticisms or
complaints that care is suffering.
Advocate for older adults. The priorities of society and professions
change. History shows us that at different times, the spotlight has
focused on various underserved groups, such as children, pregnant
women, the mentally ill, the disabled, substance abusers, and, most
recently, older adults. As interests and priorities shift to new groups,
gerontological nurses must make certain that the needs of older
individuals are not forgotten or shortchanged.
As gerontological nursing continues to shed its image of a less-than-

challenging specialty for less-than-competent nurses and fully emerges as
the dynamic, multifaceted, and opportunity-filled area of nursing that it is, it
will be recognized as a specialty for the finest talent the profession has to
offer. Gerontological nursing has just begun to show its true potential.
Knowledge and Perceptions About Aging and

Frailty: An Integrative Review of the Literature
Source: Parish, A., Kim, J., Lewallen, K. M., Miller, S., Myers, J.,
Panepinto, R., et al. (2019). Geriatric Nursing , 40 (1), 13–24.
Hypothesizing that community-based adults have a poor understanding
of the concept of frailty and that little information exists describing this lack
of knowledge, this research, conducted by a team of nurses, aimed to do an
integrative review to create a conceptual model that presented a description
of public knowledge and perceptions of aging and frailty.
Twenty-three studies (6 quantitative, 11 qualitative, and 6 mixed-
methods) were included in the review. Of the studies:
None characterized the relationship between knowledge and

perceptions of aging and health behaviors.
Two found a relationship between stereotypes about aging and aging-
related anxiety.
There was an underexploration of the relationship between older
adults’ values and knowledge of aging and health behaviors.
None linked perceptions of aging with measured health behaviors,
although some studies described the manner in which an individual’s
perception of aspects that affect aging influence health behaviors.
Only two studies addressed lay perceptions of frailty; participants
viewed frailty holistically, affecting all aspects of a person.
The authors concluded that greater understanding of aging and frailty

from a scientific perspective is needed.
This study reinforces the importance of the gerontological nurse’s roles
as educator and advocate. Despite considerable information about factors
influencing aging and frailty, the average lay person lacks information
about this relationship. The gerontological nurse can explore opportunities
to educate lay people (e.g., via community fairs, articles in lay magazines,
presentations at social group functions, etc.). In addition, nurses can
advocate for more research into how the relationship of knowledge about
aging and frailty affects health behaviors, as well as interventions to
enhance consumer knowledge.
PRACTICE REALITIES
Nurse Yen is a new graduate of a BSN program who has joined the staff of
a subacute care unit of the local hospital. Most of the nurses on staff are
diplomas and ADN graduates who have been out of school for more than a
decade.
Ms. Yen notices that some of the nurses are unaware of current best
practices and trends. In informal conversations, she has learned that none of
the nurses subscribes to professional journals or belongs to a professional
association, and the rare times they have attended continuing education
programs was when the hospital sent them.
What can Nurse Yen do to help these nurses understand the importance
and engage in continuing education?

1. What were some of the reasons for the poor status of gerontological
nursing in the past?
2. Why is the nursing role of healer particularly meaningful to
gerontological practice?
3. What theme regarding the involvement of the older adult is apparent in
the ANA Standards of the Gerontological Nurse?
4. Describe several issues that could warrant gerontological nursing
research activities.
5. Describe how the increased use of holistic practices could have a
positive effect on cost and consumer satisfaction.
6. Outline functions that could be performed by a gerontological nurse in
the roles of (a) assisted-living community preadmission health
screener, (b) health counselor in a retirement community, (c) caregiver
trainer, (d) industrial preretirement health educator, and (e) faith
community nurse.
Chapter Summary
Although nurses have a long history of caring for older adults, the formal
creation of a specialty of gerontological nursing did not occur until the
1970s. Since that time the specialty has grown considerably with the
creation of standards, clarification of competencies, and development of
several organizations that address the unique needs of nurses in this
specialty. As the specialty has developed, there has been differentiation
between geriatric nursing, which involves the nursing care of sick older
adults, and gerontological nursing, which promotes wellness and healthy
aging for all individuals.
The major roles for gerontological nurses include that of healer,
caregiver, educator, advocate, and innovator. There also are advanced
practice roles for nurses in this specialty.
To effectively care for others, gerontological nurses must care for
themselves. This includes positive health care practices, having positive
connections with others, attending to spiritual needs, and taking time for
self. These practices not only promote health in nurses themselves but
enable nurses to serve as models of healthy aging practices to others.
Gerontological nurses face challenges as the specialty continues to
grow, such as assuring practice is based on evidence, advancing research,
promoting integrative care, educating caregivers, developing new roles
within the specialty, and balancing quality care with pressures to control
health care costs.
Online Resources
Agency for Healthcare Research and Quality
www.ahrq.gov
American Holistic Nurses Association
http://www.ahna.org
American Nurses Credentialing Center
http://www.nursingworld.org/ancc
Hartford Institute for Geriatric Nursing
http://www.hartfordign.org
References
Bishop, L. F. (1904). Relation of old age to disease with illustrative cases. American Journal of
Nursing , 4 (4), 674.
DeWitt, K. (1904). The old nurse. American Journal of Nursing , 4 (4), 177.
Nightingale, F. (1860). Notes on nursing: What it is, and what it is not. New York, NY: D. Appleton
and Company.
Nouwen, H. J. M. (1990). The wounded healer. New York, NY: Doubleday.
CHAPTER 7
Holistic Assessment and Care
Planning
Chapter Outline
Holistic Gerontological Care
Holistic Assessment of Needs
Gerontological Nursing Processes
Examples of Application
The Healer Role of the Nurse
LEARNING OBJECTIVES
1. Explain holistic gerontological nursing care.

2. Describe the needs of older adults pertaining to the promotion of health
and the management of health challenges.
3. List the requisites that influence older persons’ abilities to meet self-
care needs.
4. Describe the general types of nursing interventions that are employed
when older adults present self-care deficits.
5. Describe four characteristics of nurses who function as healers.
TERMS TO KNOW
Holisticpertains to whole person; body, mind, and spirit
Presencebeing totally “with” or engaged with another individual
Surviving to old age is a tremendous accomplishment. Basic life
requirements such as obtaining adequate nutrition, keeping oneself
relatively safe, and maintaining the body’s normal functions have been met
with some success to survive to this season of life. Older adults have
confronted and overcome to varying degrees the hurdles of coping with
crises, adjusting to change, and learning new skills. Throughout their lives,
older individuals have faced many important decisions, such as should they:
Leave their country of birth to make a fresh start in America?

Stay in the family business or seek a job in a local industry?
Risk their lives to defend a cause in which they believe?
Encourage their children to fight in an unpopular war?
Invest their entire savings in launching a business of their own?
Allow their children to continue their education when the children’s
employment would ease a serious financial hardship?
Too often, nurses seek external resources to meet the needs of older
persons rather than recognizing that older adults have considerable inner
resources for self-care and empowering them to use these strengths. Older
adults then become passive recipients of care rather than active participants.
This seems unreasonable because most older adults have had a lifetime of
taking care of themselves and others, making their own decisions, and
meeting life’s most trying challenges. They may become angry or depressed
at being forced to forfeit their decision-making functions to others. They
may unnecessarily develop feelings of dependency, uselessness, and
powerlessness. Gerontological nurses must recognize and mobilize the
strengths and capabilities of older people so that they can be responsible
and active participants in, rather than objects of, care. Tapping the resources
of older individuals to enable them to actively participate in their own care
promotes normalcy, independence, and individuality; aids in reducing risks
of secondary problems related to the reactions of older adults to an
unnecessarily imposed dependent role; and honors their wisdom,
experience, and capabilities.
KEY CONCEPT
Older individuals have had to be strong and resourceful to navigate the
stormy waters of life. Nurses should not overlook these strengths when
planning care for older adults.
HOLISTIC GERONTOLOGICAL CARE

As the word implies, holism refers to the whole person—that is, the
physical, mental, emotional, social, and spiritual facets that create a being
that is greater than the sum of his or her individual parts. To view a person
from a holistic perspective is to recognize the uniqueness and complexities
of that individual. A holistic approach to gerontological care requires that
knowledge and skills from a variety of disciplines be utilized to address the
physical, mental, social, and spiritual health of individuals. Holistic
gerontological care is concerned with:
Facilitating growth toward wholeness

Promoting recovery and learning from an illness
Maximizing quality of life when one possesses an incurable illness or
disability
Providing peace, comfort, and dignity as death is approached
In holistic care, the goal is not to treat diseases but to serve the needs of
the total person through the healing of the body, mind, and spirit.
KEY CONCEPT
Gerontological nurses help older individuals achieve a sense of
wholeness by guiding them in understanding and finding meaning and
purpose in life; facilitating harmony of the mind, body, and spirit;
mobilizing their internal and external resources; and promoting self-care
behaviors.
Health promotion and healing through a balance of the body, mind, and
spirit of individuals are at the core of holistic care and have particular
relevance for gerontological care. The impact of age-related changes and
the effects of highly prevalent chronic conditions can easily threaten the
well-being of the body, mind, and spirit; therefore, nursing interventions to
reduce such threats are essential. Because chronic diseases and the effects
of advanced age cannot be eliminated, healing rather than curative efforts
will be most beneficial in gerontological nursing practice. Equally
significant is assisting older adults toward self-discovery in their final phase
of life so that they find meaning, connectedness with others, and an
understanding of their place in the universe.
HOLISTIC ASSESSMENT OF NEEDS

There are many evidence-based assessment tools that can be useful to
gerontological nurses. One of the most comprehensive listings of these tools
can be found at the Hartford Institute for Geriatric Nursing (see Resource
listing), which includes resources for assessment of activities of daily living
(ADL), hearing, sleep, sexuality, elder mistreatment, dementia, hospital
admission risk, and other topics. These tools can be used to supplement the
holistic assessment, which has a slightly different emphasis. Holistic
assessment identifies patient needs related to health promotion and health
challenges and also identifies the older adult’s requisites to meet these
needs.

The concept of health seems simple, yet it is quite complex. Viewing health
as the absence of disease offers little more clarity than defining cold as the
absence of hot and creates an image that begs for a more positive, broad
understanding. In regard to older adults, most of whom are living with
chronic conditions, this definition would relegate most of them to the ranks
of the unhealthy.
When asked to describe the factors that contribute to health, most
people would be likely to list the basic life-sustaining needs such as
breathing, eating, eliminating, resting, being active, and protecting oneself
from risks. These are essential to maintaining the physiological balance that
sustains life. However, the reality that we can have all of our physiological
needs satisfied, yet still not feel well, demonstrates that physiological
balance is but one component of overall health. Connection with ourselves,
others, a higher power, and nature are important factors influencing health.
The fulfillment of physiological needs and a sense of being connected
promote well-being of the body, mind, and spirit that enables us to
experience gratification through achieving purpose, pleasure, and dignity.
This holistic model demonstrates that optimal health includes those
activities that not only enable us to exist but also help us to realize effective,
enriched lives (Fig. 7-1).
FIGURE 7-1 Health promotion–related needs.

POINT TO PONDER
What does it mean to you to be healthy and whole?
An improved definition of health includes consideration of the root

meaning of the word health: whole. Using this foundation, health is
understood as a state of wholeness…an integration of body, mind, and spirit
to achieve the highest possible quality of life each day (Fig. 7-2). For some
individuals, this can mean exercising at the gym, engaging in challenging
work, and having a personal relationship with God; for others, it can
represent propelling oneself in a wheelchair to a porch, enjoying the beauty
of nature, and connecting with a universal energy.
FIGURE 7-2 Rather than being limited to meaning the

absence of disease, health implies a wholeness and
harmony of body, mind, and spirit.
Views of health differ not only from individual to individual but also
within the same individual from one time to another. Health priorities and
expectations in a 70-year-old person may not resemble what they were
when that individual was half that age. Cultural and religious influences can
also affect one’s view of health.
Optimal health of older adults rests on the degree to which the needs for
physiological balance, connection, and gratification are satisfied. There is
the risk that in busy clinical settings, the less tangible needs of gratification
and connection can be overlooked; as advocates for older adults,
gerontological nurses must assure that comprehensive care is provided by
not omitting these important needs.

An unfortunate reality is that most older adults live with at least one chronic
condition that challenges their health status. In fact, most involvement that
nurses have with older adults typically involves assisting them with the
demands imposed by health challenges. Older adults with acute or chronic
conditions have the same basic health promotion needs as healthy
individuals (i.e., physiological balance, connection, and gratification);
however, their conditions may create new needs such as:
Education: As individuals face a new diagnosis, they need to

understand the condition and its care.
Counseling: A health condition can trigger a variety of feelings and
impose lifestyle adjustments.
Coaching: Just as athletes and musicians require the skills of a
professional who can bring out the best in them, patients, too, can
benefit from efforts to improve compliance and motivation.
Monitoring: The complexities of health care and the changing status of
aging people warrant oversight from the nurse who can track progress
and needs.
Coordination: Older adults with a health condition often visit several
health care providers; assistance with scheduling appointments,
following multiple instructions, keeping all members of the team
informed, and preventing conflicting treatments are often needed.
Therapies: Often, health conditions are accompanied by the need for
medications, exercises, special diets, and procedures. These therapies
can include conventional ones that are commonly used in mainstream
practice or complementary ones, such as biofeedback, herbal remedies,
acupressure, and yoga. Patients may need partial or total assistance as
they implement these treatments.
Advocacy: There are times when older adults may need support or
interception with an issue. This could involve a nurse encouraging an
older adult to express her objection to a treatment that the physician
and her family are pressuring her to accept or assisting a nursing home
resident in contacting the state ombudsman if the resident believes
there is mismanagement of his funds.

As straightforward and clear as the health promotion and health challenges–
related needs may seem, these needs are met with varying degrees of
success because they are dependent on several factors unique to the patient.
Nurses assess older adults’ requisites to meet needs to determine areas for
intervention.
Physical, Mental, and Socioeconomic Abilities

An individual relies on several factors to meet even the most basic life
demands. For example, to normally fulfill nutritional needs, a person must
have the ability to experience hunger sensations; proper cognition to
adequately select, prepare, and consume food; good dental status to chew
food; a functional digestive tract to utilize ingested food; energy to shop and
prepare food; and the funds to purchase food. Deficits in any of these areas
can create risks to nutritional status. A variety of nursing interventions can
be used to reduce or eliminate physical, mental, and socioeconomic deficits.
Knowledge, Experience, and Skills

Limitations exist when the knowledge, experience, or skills required for a
given self-care action are inadequate or nonexistent. An individual with a
wealth of social skills is capable of a normal, active life that includes
friendship and other social interaction. People who have knowledge of the
hazards of cigarette smoking will be more capable of protecting themselves
from health risks associated with this habit. An older man who is widowed,
however, may not be able to cook and provide an adequate diet for himself,
having always depended on his wife for meal preparation. Similarly, the
person who has diabetes and cannot self-inject the necessary insulin may
not be able to meet the therapeutic demand for insulin administration.
Specific nursing considerations for enhancing self-care capacities are
offered in other chapters.
Desire and Decision to Take Action

The value a person sees in performing the action, as well as the person’s
knowledge, attitudes, beliefs, and degree of motivation, influences the
desire and decision for action. Limitations result if a person lacks desire or
decides against action. If an individual is not interested in preparing and
eating meals because of social isolation and loneliness, a dietary deficiency
may develop. A hypertensive individual’s lack of desire and decision not to
forfeit potato chips and pork products in the diet because of an attitude that
it is not worth the trade-off may create a real health threat. The person who
is not informed of the importance of physical activity may not realize the
need to arise from bed during an illness and consequently may develop
complications. Values, attitudes, and beliefs are deeply established and not
easily altered. Although the nurse should respect the right of individuals to
make decisions affecting their lives, if limitations restrict their ability to
meet self-care demands, the nurse can help by explaining the benefit of a
particular action, providing information, and motivating. In some
circumstances, as with an emotionally ill or mentally incompetent person,
personal desires and decisions may have to be superseded by professional
judgments.
KEY CONCEPT
There can be vastly different reasons for older adults to have a deficit in
meeting a similar need. This challenges the gerontological nurse to
explore the unique and sometimes subtle dynamics of each older
person’s life.
PROCESSES
The assessment process considers patients’ effectiveness in meeting needs
related to health promotion and health challenges. If the individual is
successful in fulfilling needs, there is no need for nursing intervention
except to reinforce the capability for self-care. When the older adult does
not have the requisites to meet needs independently, however, nursing
interventions are needed. Nursing interventions are directed toward
empowering the older individual by strengthening self-care capacities,
eliminating or minimizing self-care limitations, and providing direct
services by acting for, doing for, or assisting the individual when
requirements cannot be independently fulfilled (Fig. 7-3). Assessment
factors pertaining to specific systems and areas of function are found in the
related chapters throughout this book.
FIGURE 7-3 If the nurse identifies self-care deficits in
the older adult for meeting health promotion– and health
challenges–related needs, nursing interventions are
needed.
EXAMPLES OF APPLICATION
Nursing care for older persons is often associated with implementing
actions when health conditions exist. When individuals face health
challenges, new needs frequently arise, such as administering medications,
observing for specific symptoms, and performing special treatments; these
needs exceed and may affect the needs related to health promotion. In
geriatric nursing, consideration must be given to assessing the impact of the
health challenge on the individual’s self-care capacity and identifying
appropriate nursing interventions to ensure that the needs related to both
health promotion and the management of health challenges are adequately
met. During the assessment, the nurse identifies the specific health
challenges–related needs that are present and the requisites (e.g., physical
capability, knowledge, and desire) that need to be addressed to strengthen
self-care capacity.
It is significant that interventions include those actions that can
empower the older individual to achieve maximum self-care in regard to
health challenges–related needs. Figure 7-3 demonstrates how the holistic
self-care model becomes operational in geriatric nursing practice. The cases
that follow demonstrate the application of this model.
KEY CONCEPT
More effort may be needed to instruct and coach an older person to
perform a self-care task independently, and more time may be taken for
the person to perform the task independently than would be necessary if
a caregiver did the task; however, the benefits of independence to the
older person’s body, mind, and spirit are worth the investment.
CONSIDER THIS CASE

Mr. R, who has lived with diabetes for a
long time, administers insulin daily and follows a diabetic diet. Because of
a recent urologic problem, he may now need to take antibiotics daily and
perform intermittent self-catheterization. During the assessment, the nurse
identifies the presence of illness-imposed needs. For instance, Mr. R
performs self-catheterization according to procedure and is administering
his antibiotics as prescribed, but he is not adhering to his diabetic diet and
alters his insulin dosage based on “how he feels that day.” Mr. R has
knowledge of the diabetic diet and wants to comply; however, he had
depended on his wife to prepare meals, and now that she is deceased, he
has difficulty cooking nutritious meals independently. He denies ever
being informed of the need for regular doses of his insulin and states that
he has relied on the advice of his brother-in-law, also a diabetic, who told
him to “take an extra shot of insulin when he eats a lot of sweets.”
THINK CRITICALLY
1. What is the nurse’s next step once Mr. R’s needs have been
identified?
2. What factors must be considered in exploring Mr. R’s deficits in
meeting his health challenges–related needs?
3. What specific actions could be planned to address Mr. R’s needs?
The following case demonstrates how this model can work.
Mrs. D, 78 years old, was admitted to a hospital service for acute
conditions with the identified problems of a fractured neck of the femur,
malnutrition, and a need for a different living arrangement. Initial
observation revealed a small-framed, frail-looking lady, with obvious signs
of malnutrition and dehydration. She was well oriented to person, place,
and time and was able to converse and answer questions coherently.
Although her memory for recent events was poor, she seldom forgot to
inform anyone who was interested that she neither liked nor wanted to be in
the hospital. Her previous and only other hospitalization was 55 years
earlier.
Mrs. D had been living with her husband and an unmarried sister for
more than 50 years when her husband died. For the 5 years following his
death, she depended heavily on her sister for emotional support and
guidance. Then her sister died, which promoted feelings of anxiety,
insecurity, loneliness, and depression.
For the year since her sister’s death, she has lived alone, caring for her
six-room home in the country with no assistance other than that from a
neighbor who did the shopping for Mrs. D and occasionally provided her
with transportation.
On the day of her admission to the hospital, Mrs. D had fallen on her
kitchen floor, weak from her malnourished state. Discovering her hours
later, her neighbor called an ambulance, which transported Mrs. D to the
hospital. Once the diagnosis of fractured femur was established, plans were
made to perform a nailing procedure, to correct her malnourished state, and
to find a new living arrangement because her home demanded more energy
and attention than she was capable of providing.
NURSING CARE PLAN 7-1 illustrates how Mrs. D’s holistic needs
directed nursing problems and related nursing actions.
NURSING CARE PLAN 7-1

HOLISTIC CARE FOR MRS. D
NEEDS: Respiration and Circulation
Nursing Problems:(1) Mobility difficulties related to fracture and (2)
impaired respiration
Goals:The patient demonstrates signs of adequate respiration, is free
from respiratory distress and infection, and is free from signs of impaired
circulation.
NEEDS: Nutrition and Hydration

Nursing Problem: Insufficient dietary intake related to depression and
loneliness
Goals: The patient consumes at least 1,500 mL of fluids and 1,800
calories of nutrients daily; increases weight to 125 lb.
NEED: Elimination
Nursing Problems: (1) Potential for constipation related to immobility
and (2) potential for infection related to malnutrition and interferences
with normal bathing
Goals: The patient is free from infection, establishes a regular bowel
elimination schedule, is free from constipation, and is clean and odor
free.
NEED: Movement
Nursing Problems: (1) Reduced activity level related to malnutrition
and fracture and (2) difficulty moving and ambulating related to fracture
Goals: The patient maintains/achieves sufficient range of joint motion to
engage in ADL and is free from complications secondary to immobility.
NEED: Rest
Nursing Problem: Poor quality and quantity of sleep related to hospital
environment and movement limitations associated with fracture
Goals: The patient obtains sufficient sleep to be free from fatigue and
learns measures to facilitate sleep and rest.
NEED: Comfort
Nursing Problem: Pain related to fracture
Goals: The patient is free from pain and is able to participate in ADLs
without pain-related restrictions.
NEED: Immunity
Nursing Problem: Potential for Infection
Goals: The patient is free from infection.
NEED: Risk Reduction

Nursing Problems: (1) Potential for injury related to sensory deficits;
(2) risk of skin breakdown related to immobility, malnutrition, and
decreased sensations; and (3) reduced ability to care for home related to
altered health state, convalescence
Goals: The patient is free from injury; possesses intact skin; effectively
and correctly uses assistive devices, eyeglasses, and hearing aids (as
prescribed) to compensate for sensory deficits; and has safe, acceptable
living arrangements after discharge.
NEED: Connection
Nursing Problems: (1) Emotional and spiritual challenges related to
hospitalization, health state, and lifestyle changes and (2) reduced social
interactions related to hospitalization and health state
Goals: The patient expresses satisfaction with the amount of social
interaction, identifies means for fulfilling spiritual needs, and is free
from signs of emotional distress.
NEED: Gratification
Nursing Problems: (1) Emotional distress related to hospitalization and
health state, (2) reduced social interactions related to hospitalization, and
(3) change in self-concept related to health problems and life situation
Goals: The patient demonstrates preinjury level of physical activity,
performs self-care activities to maximum level of independence,
expresses satisfaction with the amount of solitude, and is free from signs
of emotional distress.
COMMUNICATION TIP
A skillful assessment and comprehensive care plan mean little if the
information remains in the record without being communicated to
caregivers. A mechanism should be developed to share the care plan
in a format that can be easily used by caregivers and on a level
appropriate for them.
THE HEALER ROLE OF THE NURSE
Nurses are not merely task-doers but important instruments of their
patients’ healing process. If completion of tasks was all that constituted
nursing care, robots could easily replace nurses. After all, technology exists
that could enable a machine to administer a medication, reposition a patient,
monitor vital signs, record significant events, and perform other common
tasks. Yet the nursing profession emerged as a healing art characterized by
its practitioners offering comfort, compassion, support, and caring—factors
that were equally (and perhaps sometimes more) important to patients’
healing than the procedural tasks of caregiving. Nurses serve a healer role
when their interactions assist patients in returning to wholeness (i.e.,
optimal function and harmony among body, mind, and spirit). Nurses who
support holism and healing do not sit on the sidelines as observers; they
actively engage in patients’ healing processes. This level of engagement is
similar to that of the dance instructor who takes the student by the hand and
demonstrates the correct steps instead of merely offering directions from the
sidelines.
KEY CONCEPT
Nurses actively engage in the patient’s dance of healing—teaching,
guiding, modeling, coaching, encouraging, and helping the patient
through the various steps.
Characteristics that enable nurses to engage as healers for older adults
include presence , availability, willingness to form connections, and being
models of holism.
Presence
The ability to be present in the moment also characterizes nurse healers.
Despite the many real activities that nurses typically must complete, the
“busyness” of the average clinical setting, and the unending “to do” list
lingering over them, nurse healers are able to protect their interactions with
patients from distractions. When with patients, they are with them, giving
their full, undivided attention. They actively listen; hear what patients are
saying—and not saying—and use their senses to detect subtle clues about
needs. Even if the time spent with individual patients is brief, the time fully
belongs to their patients.
POINT TO PONDER
Reflect on an interaction in which the person with whom you were
speaking seemed distracted and hurried. How did that influence your
communication?
Availability
Nurse healers display availability of body, mind, and spirit. They provide
the time and space for patients to express, explore, and experience. “That’s
not my job” are words seldom heard from nurse healers. For example, a
nurse may be monitoring a patient who is recovering from cataract surgery
in an outpatient surgical unit when the patient confides to the nurse that he
is distressed at learning that his grandchild was arrested for possession of
illegal drugs. A response from the nurse along the lines of “You shouldn’t
worry about that now” gives the message that the nurse is not available to
discuss the patient’s concern and most likely will close the door to further
discussion. By contrast, responding, “This must be very difficult for you”
could be more helpful in conveying openness and interest. Although the
nurse in the latter example may not be able to provide all the possible
assistance that the patient may require, he or she can allow the patient the
safe space to unload this burden on his mind and offer suggestions for
follow-up help.
Willingness to Form Connections

Nurse healers make connections with their patients. They engage with
patients in meaningful ways that require openness, respect, acceptance, and
a nonjudgmental attitude. They commit to learning about what makes each
patient a unique individual—the life journey that has been traveled, the
story that has formed. At times, this may require that nurses offer insights
from their own journeys and share some of the chapters from their lives.
Exploring the unique threads that have been woven into the tapestry of a
patient’s life facilitates connection.
Models of Holism
Effective nurse healers are models of holism, which begins with good self-
care practices. They not only eat a proper diet, exercise, obtain adequate
rest, and follow other positive health practices but also are attentive to their
emotional and spiritual well-being. Integrity demands that nurses know
what they want others to know and behave as they want others to behave.
Self-care also is essential to performing any other role as a nurse healer.
The Establishment of a Shared Care Plan as It Is

Experienced by Elderly People and Their Next of
Kin: A Qualitative Study
Source: Kristensson, J., Andersson, M., & Condelius, A. (2018). Archives of
Gerontology and Geriatrics , 79 (6), 131–136.
Nursing outcomes can be improved when older adults with complex
needs understand and participate in developing their care plans.
Recognizing this fact, the authors of this study explored the process of
establishing a shared care plan with older adults and their next of kin.
The study found that the process of establishing a shared care plan fell
into three categories: preparation, content, and results. The researchers
discovered that efforts to prepare the older adults and their families for the
joint care plan meeting were minimal, and often the purpose was unclear to
them. The content of the joint care plan meeting tended to be unstructured;
the focus was often on general conversation and practical matters rather
than discussion of the plan of care. The researchers concluded that to
support person-centered care and produce the desired results, older adults
must be an active, equal partner in the process.
Nurses need to consider that even if a care plan looks ideal, it may not
have full value if it is not understood or supported by patients. It can be
beneficial to arrange uninterrupted time with patients and others whom they
would like to participate in their care plan; during that meeting, the nurse
can discuss care needs in a manner they can understand, suggest actions and
interventions, provide information and instruction as needed, discuss
patients’ acceptance of those actions and interventions, and adjust as
needed. Patients and their significant others are more likely to accept and
adhere to a care plan that they understand and contributed to developing
than one that is not developed and shared with them.
PRACTICE REALITIES
As a new staff member of a nursing home, you notice that other staff make
decisions and perform activities for many residents who seem capable of
doing these things for themselves. When caring for some of these residents,
you give them the opportunity to make choices about their preferences,
which they have been pleased and able to make. In addition, when
encouraging them to feed themselves, residents have performed the task,
although more time was required to complete care.
What could be the possible reasons for staff creating unnecessary
dependence in the residents? How could you encourage a change in their
approaches?

1. Identify life experiences that have been unique to today’s older
population and that have prepared them to cope with some of the
challenges of old age.
2. List age-related changes that could affect each of the health
promotion–related needs.
3. What are some reasons for older adults not wanting to function
independently in self-care activities?
4. Describe some situations in which older adults are at risk for losing
independence as a result of nurses doing for them rather than
promoting independence.
Chapter Summary
Holistic gerontological care integrates the biologic, psychological, social,
and spiritual dimensions of an individual in which the synergy creates a
sum that is greater than its parts. It is concerned with not only the treatment
of illnesses but also the facilitation of growth toward wholeness,
maximization of quality of life, and the provision of peace, comfort, and
dignity during the dying process.
Holistic gerontological nursing assessment considers physiological
balance, the connection of the individual with self, others, the culture, and
the environment, and the degree to which the person is achieving
gratification. When health challenges are present, the individual may
present new needs, such as for education, counseling, coaching, monitoring,
coordination, therapies, and advocacy. The requisites that must be present
for the individual to meet these needs are physical, mental, and
socioeconomic abilities; knowledge, experience, and skills; and the desire
and decision to take action.
Nurses need to recognize the considerable inner resources that older
adults possess and mobilize these resources to actively engage these
individuals in their own care. Doing so will empower older adults and
facilitate commitment to the plan of care.
Online Resources
American Holistic Health Association
http://www.ahha.org
http://www.ahna.org
Hartford Institute for Geriatric Nursing Try This Assessment Tool
Series
http://hartfordign.org/practice/try_this/
CHAPTER 8
Legal Aspects of Gerontological
Nursing
CHAPTER OUTLINE
Laws Governing Gerontological Nursing Practice
Legal Risks in Gerontological Nursing
Malpractice
Confidentiality
Patient Consent
Patient Competency
Staff Supervision
Medications
Restraints
Telephone Orders
Advance Directives and Issues Related to Death and Dying
Elder Abuse
Legal Safeguards for Nurses
LEARNING OBJECTIVES
1. Discuss laws governing gerontological nursing practice.

2. Describe legal issues in gerontological nursing practice and ways to
minimize risks.
3. List legal safeguards for nurses.
TERMS TO KNOW
Consentgranting of permission to have an action taken or procedure
performed
Durable power of attorneyallows competent individuals to appoint
someone to make decisions on their behalf in the event that they
become incompetent
Dutya relationship between individuals in which one is responsible or has
been contracted to provide service for another
HIPAAHealth Insurance Portability and Accountability Act of 1996,
assures confidentiality of health information and consumers’ access to
their health records
Injuryphysical or mental harm to another or violation of a person’s rights
resulting from a negligent act
Malpracticedeviation from standard of care
Negligencefailure to conform to the standard of care
Private lawgoverns relationships between individuals and/or
organizations
Public lawgoverns relationships between private parties and the
government
Standard of carethe norm for what a reasonable individual in a similar
circumstance would do
Like nurses in every specialty, gerontological nurses must be cognizant of

the legal aspects of their practice. In fact, legal risks can intensify and legal
questions can arise when working in geriatric care settings. Frequently,
gerontological nurses are in highly independent and responsible positions in
which they must make decisions without an abundance of professionals
with whom to confer. They are also often responsible for supervising
unlicensed staff and ultimately are accountable for the actions of those they
supervise. In addition, gerontological nurses are likely to face difficult
situations in which their advice or guidance may be requested by patients
and families; they may be asked questions regarding how to protect the
assets of the wife of a patient with Alzheimer’s disease, how to write a will,
what can be done to cease life-sustaining measures, and who can give
consent for a patient. Also, the multiple problems faced by older adults,
their high prevalence of frailty, and their lack of familiarity with laws and
regulations may make them easy victims of unscrupulous practices.
Advocacy is an integral part of gerontological nursing, reinforcing the need
for nurses to be concerned about protecting the rights of their older patients.
To fully protect themselves, their patients, and their employers, nurses must
have knowledge of basic laws and ensure that their practice falls within
legally sound boundaries.
LAWS GOVERNING
PRACTICE
Laws are generated from several sources. Because many laws are developed
at the state and local levels, variation exists among the states. This variation
necessitates nurses’ familiarity with the unique laws within their specific
states, particularly those governing professional practice, labor relations,
and regulation of health care agencies.
There are both public and private laws. Public law governs
relationships between private parties and the government and includes
criminal law and regulation of organizations and individuals engaged in
certain practices. The scope of nursing practice and the requirements for
being licensed as a home health agency fall under the enforcement of public
law. Private law governs relationships among individuals or between
individuals and organizations and involves contracts and torts (i.e.,
wrongful acts against another party, including assault, battery, false
imprisonment, and invasion of privacy). These laws protect individual
rights and also set standards of conduct, which, if violated, can result in
liability of the wrongdoer.
In addition to laws, there are voluntary standards by which a nurse can
be judged. The American Nurses Association publication Gerontological
Nursing: Scope and Standards of Practice provides guidelines for
gerontological nurses that offer descriptions of what is considered safe and
effective care. (See Chapter 6 for a discussion of these standards.)
LEGAL RISKS IN GERONTOLOGICAL
NURSING
Most nurses do not commit wrongful acts intentionally; however, certain
situations can increase the nurse’s risk of liability. Such situations include
working without sufficient resources, not checking agency policy or
procedure, bending a rule, giving someone a break, taking shortcuts, or
trying to work when physically or emotionally exhausted. Not only repeated
episodes of carelessness but also the one-time deviation from standards can
result in serious legal problems. Box 8-1 reviews some of the general acts
that could make nurses liable for violating the law. Nurses must be alert to
all the potential legal risks in their practice and make a conscious effort to
minimize them. Some of the issues that could present legal risks for nurses
are presented below.
BOX 8-1 Acts That Could Result in Legal

Liability for Nurses
ASSAULT
A deliberate threat or attempt to harm another person that the person
believes could be carried through (e.g., telling a patient that he will be
locked in a room without food for the entire day if he does not stop being
disruptive).
BATTERY
Unconsented touching of another person in a socially impermissible
manner or carrying through an assault. Even a touching act done to help
a person can be interpreted as battery (e.g., performing a procedure
without consent).
DEFAMATION OF CHARACTER
An oral or written communication to a third party that damages a
person’s reputation. Libel is the written form of defamation; slander is
the spoken form. With slander, actual damage must be proven, except
when:
Accusing someone of a crime
Accusing someone of having a loathsome disease
Making a statement that affects a person’s professional or business
activity
Calling a woman unchaste
Defamation does not exist if the statement is true and made in good
faith to persons with a legitimate reason to receive the information.
Stating on a reference that an employee was fired from your agency for
physically abusing patients is not defamation if, in fact, the employee
was found guilty of those charges. However, stating on a reference that
an employee was a thief because narcotics were missing every time he or
she was on duty can be considered defamation if the employee was never
proved guilty of those charges.
FALSE IMPRISONMENT
Unlawful restraint or detention of a person. Preventing a patient from
leaving a facility is an example of false imprisonment, unless it is shown
that the patient has a contagious disease or could harm himself or herself
or others. Actual physical restraint need not be used for false
imprisonment to occur: telling a patient that he or she will be tied to the
bed if he or she tries to leave can be considered false imprisonment.
FRAUD
Willful and intentional misrepresentation that could cause harm or cause
a loss to a person or property (e.g., selling a patient a ring with the claim
that memory will be improved when it is worn).
INVASION OF PRIVACY
Invading the right of an individual to personal privacy. Can include
unwanted publicity, releasing a medical record to unauthorized persons,
giving patient information to an improper source, or having one’s private
affairs made public. (The only exceptions are reporting communicable
diseases, gunshot wounds, and abuse.) Allowing a visiting student to
look at a patient’s pressure ulcers without permission can be an invasion
of privacy.
LARCENY
Unlawful taking of another person’s possession (e.g., assuming that a
patient will not be using his or her personally owned wheelchair
anymore and giving it away to another patient without permission).
NEGLIGENCE
Omission or commission of an act that departs from acceptable and
reasonable standards, which can take several forms:
Malfeasance: committing an unlawful or improper act (e.g., a nurse

performing a surgical procedure)
Misfeasance: performing an act improperly (e.g., including the
patient in a research project without obtaining consent)
Nonfeasance: failure to take proper action (e.g., not notifying the
physician of a serious change in the patient’s status)
Malpractice: failure to abide by the standards of one’s profession
(e.g., not checking that a nasogastric tube is in the stomach before
administering a tube feeding)
Criminal negligence: disregard to protecting the safety of another
person (e.g., allowing a confused patient, known to have a history
of starting fires, to have matches in an unsupervised situation)
Malpractice
Nurses are expected to provide services to patients in a careful, competent
manner according to a standard of care . The standard of care is
considered the norm for what a reasonable individual in a similar
circumstance would do. When performance deviates from the standard of
care, nurses can be liable for malpractice. Examples of situations that could
lead to malpractice include the following:
Administering the incorrect dosage of a medication to a patient,

thereby causing the patient to experience an adverse reaction
Identifying respiratory distress in a patient but not informing the
physician in a timely manner
Leaving an irrigating solution at the bedside of a confused patient, who
then drinks that solution
Forgetting to turn an immobile patient during the entire shift, resulting
in the patient developing a pressure injury
Having a patient fall because one staff member attempted to lift the
patient manually when the use of a lift device was the standard
The fact that a negligent act occurred in itself does not warrant that
damages be recovered; instead, it must be demonstrated that the following
conditions were present:
Duty : a relationship between the nurse and the patient in which the
nurse has assumed responsibility for the care of the patient
Negligence : failure to conform to the standard of care (i.e.,
malpractice)
Injury : physical or mental harm to the patient or violation of the
patient’s rights resulting from the negligent act
KEY CONCEPT
Duty, negligence, and injury must be present for malpractice to exist.
The complexities involved in caring for older adults, the need to

delegate responsibilities to others, and the many competing demands on the
nurse contribute to the risk of malpractice. As the responsibilities assumed
by nurses increase, so will the risk of malpractice. Nurses should be aware
of the risks in their practice and be proactive in preventing malpractice
(Box 8-2). Also, it is advisable for nurses to carry their own malpractice
insurance and not rely only on the insurance provided by their employers.
Employers may refuse to cover nurses under their policy if it is believed
they acted outside of their job descriptions; further, jury awards can exceed
the limits of employers’ policies.
BOX 8-2 Recommendations for Reducing the

Risk of Malpractice
Be familiar with and follow the nurse practice act that governs
nursing practice in the specific state.
Keep current of and adhere to policies and procedures of the
employing agency.
Ensure that policies and procedures are revised as necessary.
Do not discuss a patient’s condition, share patient information, or
allow access to a patient’s medical record to anyone unless the
patient has provided written consent.
Do not post a patient’s photograph, name, or any other identifying
information on social media.
Consult with the physician when an order is unclear or
inappropriate.
Know patients’ normal status and promptly report changes in status.
Assess patients carefully and develop realistic care plans.
Read patients’ care plans and relevant nursing documentation
before giving care.
Identify patients before administering medications or treatments.
Document observations about patients’ status, care given, and
significant occurrences.
Assure that documentation by self and subordinates is accurate and
that documentation reflects care that actually was provided.
Know the credentials and assure competency of all subordinate
staff.
Discuss with supervisory staff assignments that cannot be
completed due to insufficient staff or supplies.
Do not accept responsibilities that are beyond your capabilities to
perform and do not delegate assignments to others unless you are
certain that they are competent to perform the delegated tasks.
Report broken equipment and other safety hazards.
Report or file an incident report when unusual situations occur.
Promptly report all actual or suspected abuse to the appropriate
state and local agencies.
Attend continuing education programs and keep current of
knowledge and skills pertaining to your practice.
POINT TO PONDER
In addition to the time and money involved in defending a lawsuit, what
are some consequences of being accused of malpractice?
Other situations can cause nurses to be liable for negligence, if not

malpractice , including the following:
Failing to take action (e.g., not reporting a change in the patient’s

condition or not notifying the administration of a physician’s
incompetent acts)
Contributing to patient injury (e.g., not providing appropriate
supervision of confused patients or failing to lock the wheelchair
during a transfer)
Failing to report a hazardous situation (e.g., not letting anyone know
that the fire alarm system is inoperable or not informing anyone that a
physician is performing procedures under the influence of alcohol)
Handling patient’s possessions irresponsibly
Failing to follow established policies and procedures
POINT TO PONDER
Are you familiar with your state’s nurse practice act and the regulations
governing the area in which you practice or will practice?
Confidentiality
It is the rare patient who is seen by only one health care provider. More
often, the patient visits a variety of medical specialists, therapists,
diagnostic facilities, pharmacies, and institutions. These providers often
need to communicate information about the patient to ensure coordinated,
quality care. However, with the potentially high number of individuals who
have access to patients’ personal medical information and the ease with
which information is able to be transferred, there are increased
opportunities for confidential information to fall into unintended hands.
In an effort to protect the security and confidentiality of patients’ health
information, the federal government developed the Health Insurance
Portability and Accountability Act (HIPAA). HIPAA provides patients with
access to their medical records and control over how their personal health
information is used and disclosed. Patients can ask their providers to change
incorrect information that they have discovered in their record or to add
missing information. They also can request that their health information not
be shared. Congress authorized civil and criminal penalties for covered
entities that misuse personal health information. The Administrative
Simplification Compliance Act amended HIPAA and required all claims
submitted to Medicare be done so electronically, following guidelines to
protect patient privacy.
There can be variations in the procedures, providers, and facilities use
to review HIPAA-related facts with patients, protect patients’ information,
and communicate information related to patients. It is important that nurses
be familiar with and adhere to policies and procedures related to the
protection of patients’ privacy.
Patient Consent
Patients are entitled to know the full implications of procedures and make
an independent decision as to whether they choose to have them performed.
This may sound simple enough, but it is easy for consent to be overlooked
or improperly obtained by health care providers. For instance, certain
procedures may become so routine to staff that they fail to realize patient
permission must be granted, or a staff member may obtain a signature from
a patient who has a fluctuating level of mental competency and who does
not fully understand what he or she is signing. In the interest of helping
patients and delivering care efficiently, or from a lack of knowledge
concerning consent, staff members can subject themselves to considerable
legal liability.
Consent must be obtained before performing any medical or surgical
procedure; performing procedures without consent can be considered
battery. Usually, when patients enter a health care facility, they sign consent
forms that authorize the staff to perform certain routine measures (e.g.,
bathing, examination, care-related treatments, and emergency
interventions). These forms, however, do not qualify as carte blanche
consent for all procedures. Even blanket consent forms that patients may
sign, authorizing staff to do anything required for treatment and care, are
not valid safeguards and may not be upheld in a court of law. Consent
should be obtained for anything that exceeds basic, routine care measures.
Particular procedures for which consent definitely should be sought include
any entry into the body, either by incision or through natural body openings;
any use of anesthesia, cobalt or radiation therapy, electroshock therapy, or
experimental procedures; any type of research participation, invasive or not;
and any procedure, diagnostic or treatment, that carries more than a slight
risk. Whenever there is doubt regarding whether consent is necessary, it is
best to err on the safe side.
Consent must be informed. It is unfair to the patient and legally
unsound to obtain the patient’s signature for a procedure without telling the
patient what that procedure entails. Ideally, a written consent that describes
the procedure, its purpose, alternatives to the procedure, expected
consequences, and risks should be signed by the patient, witnessed, and
dated (Fig. 8-1). It is best that the person performing the procedure (e.g.,
the physician or researcher) be the one to explain the procedure and obtain
the consent. Nurses or other staff members should not be in the position of
obtaining consent for the physician because it is illegal and because they
may not be able to answer some of the medical questions posed by the
patient. Patients who do not fully comprehend or who have fluctuating
levels of mental function are incapable of granting legally sound consent.
Nurses can play an important role in the consent process by ensuring that it
is properly obtained, answering questions, reinforcing information, and
making the physician aware of any misunderstanding or change in the
desire of the patient. Finally, nurses should not influence the patient’s
decision in any way.
FIGURE 8-1 It is important for the patient to give
informed consent before any medical or surgical
procedure. Written consent forms should describe the
procedure, its purpose, alternatives to the procedure,
expected consequences, and risks.
COMMUNICATION TIP
When consent is being obtained, nurses should assess if the patient or
his/her representative fully understand the procedure, its purpose,
alternatives, expected consequences, and risks. If through questions,
comments, or body language there is any indication that the matter is
not understood, the nurse should ask if there are any questions or if
more information is needed and to assure the need is addressed.
Every conscious and mentally competent adult has the right to refuse
consent for a procedure. To protect the agency and staff, it is useful to have
the patient sign a release stating that consent is denied and that the patient
understands the risks associated with refusing consent. If the patient refuses
to sign the release, this should be witnessed, and both the professional
seeking consent and the witness should sign a statement that documents the
patient’s refusal for the medical record.
Patient Competency
Increasingly, particularly in long-term care facilities, nurses are caring for
patients who are confused, demented, or otherwise mentally impaired.
Persons who are mentally incompetent are unable to give legal consent.
Often in these circumstances, staff will turn to the next of kin to obtain
consent for procedures; however, the appointment of a guardian to grant
consent for the incompetent individual is the responsibility of the court.
When the patient’s competency is questionable, staff should encourage
family members to seek legal guardianship of the patient or request the
assistance of the state agency on aging in petitioning the court for
appointment of a guardian. Unless they have been judged incompetent by a
judge, people are entitled to make their own decisions.
Various forms of guardianship (also called conservatorship) can be
granted when a person has been judged incompetent (Box 8-3), each with
its own restrictions. The guardian is monitored by the court to ensure that
he or she is acting in the best interests of the incompetent individual. In the
case of a guardian of property, the guardian must file financial reports with
the court.
BOX 8-3 Kinds of Decision-Making Authority

That Individuals Can Legally Possess Over
Patients
GUARDIANSHIP
Court appointment of an individual or organization to have the authority
to make decisions for an incompetent person. Guardians can be granted
decision-making authority for specific types of issues:
Guardian of property (conservatorship): this limited guardianship

allows the guardian to take care of financial matters but not make
decisions concerning medical treatment.
Guardian of person: decisions pertaining to the consent or refusal
for care and treatments can be made by persons granted this type of
guardianship.
Plenary guardianship (committeeship): all types of decisions
pertaining to person and property can be made by guardians under
this form.
POWER OF ATTORNEY
Legal mechanism by which competent individuals appoint parties to
make decisions for them; this can take the form of
Limited power of attorney: decisions are limited to certain matters

(e.g., financial affairs) and power of attorney becomes invalid if the
individual becomes incompetent.
Durable power of attorney: provides a mechanism for continuing or
initiating power of attorney in the event the individual becomes
incompetent.
Guardianship differs from power of attorney in that the latter is a

mechanism used by competent individuals to appoint someone to make
decisions for them. Usually, a power of attorney becomes invalid if the
individual granting it becomes incompetent, except in the case of a durable
power of attorney . A durable power of attorney allows competent
individuals to appoint someone to make decisions on their behalf in the
event that they become incompetent; this is a recommended procedure for
individuals with dementias and other disorders in which competency can be
anticipated to decline.
To ensure protection of patients’ rights, nurses should recommend that
patients and their families seek legal counsel for guardianship and power of
attorney issues and, when such appointment has been made, clarify the type
of decision-making authority that the appointed parties possess.
KEY CONCEPT
A durable power of attorney can be useful for patients in the early stage
of Alzheimer’s disease because they can appoint someone to make
decisions on their behalf at a later time when they may be incompetent to
do so.
Staff Supervision
In many settings, gerontological nurses are responsible for supervising
other staff, many of whom may be unlicensed personnel. In these situations,
nurses are responsible not only for their own actions but also for the actions
of the staff they are supervising. This falls under the doctrine of respondeat
superior (“let the master answer”). Nurses must understand that if a patient
is injured by an employee they supervise while the employee is working
within the scope of the applicable job description, nurses can be liable.
Various types of situations can create risks for nurses:
Permitting unqualified or incompetent persons to deliver care

Failing to follow up on delegated tasks
Assigning tasks to staff members for which they are not qualified or
competent
Allowing staff to work under conditions with known risks (e.g., being
short staffed and improperly functioning equipment)
These are considerations that nurses need to keep in mind when they
accept responsibility for supervising the entire facility, sending an aide into
a home to deliver care without knowing the aide’s competency, or allowing
registry or other employees to work without fully orienting them to agency
policies and procedures.
KEY CONCEPT
A nurse needs to ensure that those caregivers to whom tasks are
delegated are competent to perform the tasks and carry out their
assignments properly.
Medications
Nurses are responsible for the safe administration of prescribed
medications. Preparing, compounding, dispensing, and retailing
medications fall within the practice of pharmacy, not nursing, and, when
performed by nurses, can be interpreted as functioning outside their
licensed scope of practice.

An act as seemingly benign as going into the agency’s pharmacy after
hours, pouring some tablets into a container, labeling that container, and
taking it to the unit so that a patient can receive the drug that is urgently
needed is illegal.
Restraints
The Omnibus Budget Reconciliation Act (OBRA) heightened awareness of
the serious impact of restraints by imposing strict standards on their use in
long-term care facilities. This increased concern regarding and sensitivity to
the use of chemical and physical restraints has had a ripple effect on other
practice settings.
Anything that physically or mentally restricts a patient’s movement
(e.g., protective vests, trays on wheelchairs, safety belts, geriatric chairs,
side rails, and medications) can be considered a restraint. Improperly used
restraining devices can not only violate regulations concerning their use but
also result in litigation for false imprisonment and negligence . At no time
should restraints be used for the convenience of staff.
Older adults with deliriums and dementias can pose challenges to staff
in terms of behavioral management. There are several medications (e.g.,
haloperidol, benzodiazepines, and lorazepam) that can be useful in reducing
agitation and the need for physical restraints; however, these can result in
complications such as aspiration due to depression of the gag reflex and
pneumonia due to reduced respiratory activity. It must be recognized that
these drugs are forms of chemical restraints and should only be employed
after other measures have proven ineffective. Further, nonpharmacological
strategies to manage behaviors can reduce the amount of drug needed.
Consultation with geropsychiatric specialists or psychologists can prove
beneficial in identifying other strategies.
Alternatives to restraints should be used whenever possible. Measures
to help manage behavioral problems and protect the patient include alarmed
doors, wristband alarms, bed alarm pads, beds and chairs close to the floor
level, and increased staff supervision and contact. Specific patient behavior
that creates risks to the patient and others should be documented.
Assessment of the risk posed by the patient not being restrained and the
effectiveness of alternatives should be included.
When restraints are deemed absolutely necessary, a physician’s order
for the restraints must be obtained, stating the specific conditions for which
the restraints are to be used, the type of restraints, and the duration of use.
Agency policies should exist for the use of restraints and should be
followed strictly. Detailed documentation should include the times for
initiation and release of the restraints, their effectiveness, and the patient’s
response. The patient requires close observation while restrained.
At times, staff may assess that restraint use is required, but the patient
or family objects and refuses to have a restraint used. If counseling does not
help the patient and family understand the risks involved in not using the
restraint, the agency may wish to have the patient and family sign a release
of liability that states the risks of not using a restraint and the patient’s or
family’s opposition. Although this may not free the nurse or agency from all
responsibility, some limited protection may be afforded, and, by signing the
release, the patient and family may realize the severity of the situation.
Telephone Orders
In home health and long-term care settings, nurses often do not have the
benefit of an on-site physician. Changes in the patient’s condition and
requests for new or altered treatments may be communicated over the
telephone, and, in response, physicians may prescribe orders accordingly.
Accepting telephone orders predisposes nurses to considerable risks
because the order can be heard or written incorrectly or the physician can
deny that the order was given. It may not be realistic or advantageous to
patient care to totally eliminate telephone orders, but nurses should
minimize their risks in every way possible.
Try to have the physician immediately fax the written order or send it
online (if your organization has a system for this), if possible.
Do not involve third parties in the order (e.g., do not have the order
communicated by a secretary or other staff member for the nurse or the
physician).
Communicate all relevant information to the physician, such as vital
signs, general status, and medications administered.
Do not offer diagnostic interpretations or a medical diagnosis of the
patient’s problem.
Write down the order as it is given and immediately read it back to the
physician in its entirety.
Place the order on the physician’s order sheet, indicating it was a
telephone order, the physician who gave it, time, date, and the nurse’s
signature.
Obtain the physician’s signature within 24 hours.
Recorded telephone orders may be a helpful way for nurses to validate

what they have heard, but they may not offer much protection in the event
of a lawsuit unless the physician is informed that the conversation is being
recorded or unless special equipment with a 15-second tone sound is used.

The caseloads of many gerontological nurses contain a high prevalence of
terminally ill patients. It may be understood by all parties involved that
these patients are going to die and that resuscitation attempts would be
inappropriate; however, unless an order specifically states that the patient
should not be resuscitated, failure to attempt to save that person’s life could
be viewed as negligence. Nurses must ensure that DNR (do not resuscitate)
orders are legally sound, remembering several points. First, DNR orders are
medical orders and must be written and signed on the physician’s order
sheet to be valid. DNR placed on the care plan or a special symbol at the
patient’s bedside is not legal without the medical order. Next, unless it is
detrimental to the patient’s well-being or the patient is incompetent, consent
for the decision not to resuscitate should be obtained; if the patient is unable
to consent, family consent should be sought. Finally, every agency should
develop a DNR policy to guide staff in these situations; this could be an
excellent item for an ethics committee to review.

Recall from Chapter 3 Julia Morales, who is

receiving chemotherapy and radiation for lung cancer. She has decided to
stop treatment. Lucy, her partner for more than 25 years, is supportive of
her choice and wants to care for Julia in their home. Julia’s son, Neil, is
urging her to try one more round of chemotherapy. How can the nurse
assist them with care decisions? Why is it important for the nurse to
discuss advance directives and the appointment of a health care proxy with
Julia and her family? How can the nurse establish and support Julia’s
values and preferences for care? What other health care practitioners could
the nurse call on to provide an interprofessional approach in this situation?
(The story of Julia Morales and Lucy Grey continues in Chapter 36.)
Advance Directives and Issues Related to Death

and Dying
A variety of issues surrounding patients’ deaths pose legal concern for
nurses. Some of these issues arise long before death occurs, when patients
choose to execute an advance directive or a living will. Advance directives
express the desires of competent adults regarding terminal care, life-
sustaining measures, and other issues pertaining to their dying and death.
CONSIDER THIS CASE

You are working in a nursing home that
supports a restraint-free environment. In the past month, one of the
residents has slipped once from her wheelchair and once off the edge of
her bed; she fell onto the floor both times. Although the resident was not
injured in either of these incidents, the resident’s daughter is concerned
that her mother has the potential to seriously hurt herself during a fall and
requests that her mother be restrained while in bed and in her wheelchair.
The resident has not expressed any preference but says she’ll do whatever
her daughter wants. You explain the rationale for not using restraints, but
the daughter is insistent that her mother be restrained. “You know my
mother has the tendency to slip to the floor,” the daughter says, “so if you
don’t tie her in the chair and keep her rails up when she is in bed and she
falls, I’ll have my lawyers here before you can say boo!”
THINK CRITICALLY
1. How do you decide if the resident’s freedom to be unrestrained
is worth the risk of her injuring herself during a fall?
2. What dilemmas could you present for the resident if you ask her
for her preference without consideration of the daughter’s desires?
3. How much should a facility be influenced by the threat of

litigation?
4. What can you do to safeguard the resident and the facility?
KEY CONCEPT
There are two types of advance directives. A durable power of attorney
for health care is a document that appoints a person selected by the
patient (called a health care proxy, attorney-in-fact, surrogate, or agent)
to make decisions on the patient’s behalf should the patient be unable to
make or communicate his or her decisions. A living will describes a
patient’s preferences and gives instructions to health care providers if at
a future time he or she is unable to make or communicate decisions and
has no one appointed as proxy.
In 1990, Congress passed the Patient Self-Determination Act (which

went into effect from December 1, 1991), which requires all health care
institutions receiving Medicare or Medicaid funds to ask patients on
admission if they possess a living will or durable power of attorney for
health care. The patient’s response must be recorded in the medical record.
Nurses can aid by making physicians and other staff aware of the presence
of a patient’s advance directive, informing patients of any special measures
they must take to have the document accepted into the medical record, and,
unless contraindicated, following the patient’s wishes (Fig. 8-2). Following
an advance directive protects health care professionals from civil and
criminal liability when they are followed in good faith. Nurses are advised
to check the status of advance directive legislation in their individual states.
FIGURE 8-2 Gerontological nurses guide older adults as
they consider advance directives.
Other issues arise when patients are terminally ill and dying; one such
issue involves wills. Wills are statements of individuals’ desires for the
management of their affairs after their death. For a will to be valid, the
person making it must be of sound mind and legal age and must not be
coerced or influenced into making it. The will should be written—although
under certain conditions, some states recognize oral, or nuncupative, wills
—signed, dated, and witnessed by persons not named in the will. The
required number of witnesses may vary among the states.
To avoid problems, such as family accusations that the patient was
influenced by the nurse because of his dependency on her, nurses should
avoid witnessing a will. Nurses should, however, help patients obtain legal
counsel when they wish to execute or change a will. Legal aid agencies and
local schools of law are also sources of assistance for older adults wishing
to write their wills. If a patient is dying and wishes to dictate a will to the
nurse, the nurse may write it exactly as stated, sign, and date it; have the
patient sign it if possible; and forward it to the agency’s administrative
offices for handling. It is useful for gerontological nurses to encourage
persons of all ages to develop a will to avoid having the state determine
how their property will be distributed in the event of their deaths.
The pronouncement of death is another area of concern. Nurses often
are placed in the position and are capable of determining when a patient has
died and notifying the family and funeral home. The physician is then
notified of the death by telephone and signs the death certificate at a later
time. This rather common and benign procedure actually may be illegal for
nurses because in some states, the act of pronouncing a patient dead falls
within the scope of medical practice, not nursing. Nurses should safeguard
their licenses by either holding physicians responsible for the
pronouncement of death if they are required to do so or lobbying to have
the law changed so that they are protected in these situations.
Postmortem examinations of deceased persons are useful in learning
more about the cause of death. They also contribute to medical education.
In some circumstances, such as when the cause of death is suspected to be
associated with a criminal act, malpractice, or an occupational disease, the
death may be considered a medical examiner’s case and an autopsy may be
mandatory. Unless it is a medical examiner’s case, consent for autopsy must
be obtained from the next of kin, usually in the order of spouse, children,
parents, siblings, grandparents, aunts, uncles, and cousins.
Elder Abuse
Elder abuse can occur in patients’ homes or in health care facilities by loved
ones, caregivers, or strangers. Particularly in long-term caregiving
relationships, in which family members or staff “burn out,” abuse may be
an unfortunate consequence. Factors contributing to abuse by family
caregivers are discussed in Chapter 35.
KEY CONCEPT
Caregiver stress can lead to abuse of older adults.
There are several recognized types of elder abuse (National Center for
Elder Abuse, 2019), which include the following:
Physical abuse
Emotional or psychological abuse
Sexual abuse
Financial or material exploitation
Neglect
Abandonment
Self-neglect
Abuse can assume many forms, including inflicting pain or injury ,

stealing, mismanaging funds, misusing medications, causing psychological
distress, withholding food or care, or confining a person. Even threatening
to commit any of these acts is considered abuse. Abuse may be undetected
due to an older person’s lack of contact with others (e.g., being homebound
and not having communication with anyone but the relative who is the
abuser) or due to the reluctance to report the problem due to fear or shame.
Nurses can assess for abuse using a tool such as the Elder Mistreatment
Assessment (Fulmer, 2019). Gerontological nurses must also be alert to
indications of possible abuse or neglect during routine interactions with
older adults; signs could include the following:
Delay in seeking necessary medical care

Malnutrition
Dehydration
Unexplained bruises
Poor hygiene and grooming
Urine odor, urine-stained clothing/linens
Excoriation or abrasions of genitalia
Inappropriate administration of medications
Repeated infections, injuries, or preventable complications from
existing diseases
Evasiveness in describing condition, symptoms, problems, and home
life
Unsafe living environment
Social isolation
Anxiety, suspiciousness, and depression
Nurses have a legal responsibility to report all cases of known or

suspected abuse. States vary regarding reporting mechanisms; nurses should
thus consult specific state laws. The Resources listing includes
organizations that can provide information on elder abuse and guidance on
finding attorneys to assist a person who is the victim of abuse.
LEGAL SAFEGUARDS FOR NURSES

Common sense can be the best ally of sound nursing practice. Never forget
that patients, visitors, and employees do not forfeit their legal rights or
responsibilities when they are within the health care environment. Laws and
regulations impose additional rights and responsibilities in patient–provider
and employee–employer relationships. Nurses can and should protect
themselves in the following ways:
Familiarize themselves with the laws and rules governing their specific
care agency/facility, their state’s nurse practice act, and labor relations.
Become knowledgeable about their agency’s policies and procedures
and adhere to them strictly.
Function within the scope of nursing practice.
Determine for themselves the competency of employees for whom
they are responsible.
Check the work of employees under their supervision.
Obtain administrative or legal guidance when in doubt about the legal
ramifications of a situation.
Report and document any unusual occurrence.
Refuse to work under circumstances that create a risk to safe patient
care.
Carry liability insurance

Barriers to Help Seeking for Elder Abuse: A
Qualitative Study of Older Adults
Source: Abid, M., Esmaeli, M., Zakerimoghadam, M., & Nayeri, N. D.
(2019). Geriatric Nursing, 40(6), 565–571.
According to the National Council on Aging, approximately 1 in 10
older adults experiences some type of abuse; however, only an estimated 1
in 14 of those who are abused report the abuse to authorities. This
descriptive qualitative study explored the factors that kept older adults from
reporting their abuse.
Through purposeful sampling, eighteen older adults with a known
history of abuse were interviewed. The researchers reviewed barriers to
reporting abuse and collected data. Three main categories of barriers to
seeking help for abuse were identified: personal attitude toward abuse,
inefficiency of support systems, and dependence on others.
After recognizing potential barriers to reporting abuse, nurses can
develop strategies to prevent abuse and facilitate it being reported. Actions
could include the following:
Educating groups of senior citizens about the fact that abuse is

unacceptable, and defining the types of abuse and how to report them
Teaching caregivers about the risk of abuse related to caregiver stress,
and letting them know about available support systems
Reviewing with nurses who assess older adults the factors that increase
the risk of abuse, and what signs of potential abuse they should look
out for
Despite the small sample size, this study is important for nurses to
consider in their work with older adults because it offers insight into
barriers they could face when seeking help for abuse.
PRACTICE REALITIES
You are working the night shift, where there have been several call outs on
the unit for postoperative patients. All staff are carrying a heavier than usual
load. During tonight’s shift, one of the nurses forgot to raise the side rail on
a heavily sedated patient. In his confused, sedated state, the patient tries to
get out of bed and falls. You and the assigned nurse hurry to his aid. The
other nurse tells you to help her lift the patient back to bed. You resist,
stating “He should be examined and the supervisor called.” The other nurse
objects, stating “You know the policy. They’ll either suspend or fire me and
I have kids to support. I checked him out and he is fine…and, he is too
doped up to remember anything. There won’t be any harm; come on.”
The patient doesn’t appear injured and you don’t want the nurse to be in
jeopardy of losing her job. What should you do?

1. Discuss the reasons why gerontological nursing is a high-risk specialty
for legal liability.
2. Identify the process you would follow in your community to obtain
guardianship for an incompetent older adult who has no family.
3. Describe the approach you would use to discuss the development of an
advance directive with an older adult.
4. Discuss the actions you would take if faced with the following
situations:
A nurse whom you supervise makes repeated errors and does not seem
competent to do his job.
You begin documenting your observations but are told by your
immediate supervisor to “just bite your tongue and live with it because
he is the administrator’s son.”
A patient confides in you that her son is forging her name on checks
and gradually emptying out her bank accounts.
Chapter Summary
There are legal risks associated with nursing practice in any specialty. In
gerontological nursing, the risks may be compounded by the unique
problems faced by older adults and the care settings, which may be staffed
with a high number of unlicensed caregivers. Gerontological nurses need to
understand their legal responsibilities and risks.
There are both public and private laws that must be respected in
practice. Public law governs the relationship between government and
private parties; it includes issues such as the scope of practice, regulations
that care settings must abide by, and criminal law. Private law involves the
relationships among individuals or between individuals and organizations
and includes issues such as assault, battery, false imprisonment, and
invasion of privacy. In addition, there are voluntary standards upon which
nurses can be judged, such as those developed by professional nursing
associations.
Nurses need to be proactive in protecting themselves, their
organizations, and their patients. This responsibility includes abiding by the
laws and rules governing their practice, assuring the competency of
individuals to whom care is delegated, reporting unusual circumstances and
incidents, and obtaining legal consultation as needed.
Online Resources
American Association of Retired Persons (AARP) Foundation: Legal
Advocacy
http://www.aarp.org/research/legal-advocacy/
American Association of Retired Persons (AARP) National Senior
Citizens Law Center
https://www.aarp.org/livable-communities/learn/health-wellness/info-12-
2012/national-senior-citizens-law-center.html
American Bar Association Senior Lawyers Division
http://www.abanet.org/srlawyers/home.html
Elder Justice Coalition
http://www.elderjusticecoalition.com
Elder Mistreatment and Abuse http://https://consultgeri.org/geriatric-
topics/elder-mistreatment-and-abuse
National Academy of Elder Law Attorneys
https://www.naela.com
National Center on Elder Abuse
https://ncea.acl.gov
References
Fulmer, T. (2019). Elder mistreatment assessment. Try This. Hartford Institute for Geriatric Nursing,
Issue No. 15. Retrieved January 3, 2020 from https://consultgeri.org/try-this/general-
assessment/issue-15.pdf.
National Center for Elder Abuse. (2019). Types of abuse. Retrieved January 3, 2020 from
https://ncea.acl.gov/Suspect-Abuse/Abuse-Types.aspx.
CHAPTER 9
Ethical Aspects of Gerontological
Nursing
CHAPTER OUTLINE
Philosophies Guiding Ethical Thinking
Ethics in Nursing
Ethical Principles
Ethical Dilemmas Facing Gerontological Nurses
LEARNING OBJECTIVES
1. Discuss various philosophies regarding right and wrong.

2. Describe ethical standards, principles, and cultural considerations
guiding nursing practice.
3. List factors that have increased ethical dilemmas for nurses.
4. Identify measures to help nurses make ethical decisions.
TERMS TO KNOW
Autonomyto respect individual freedoms, preferences, and rights
Beneficenceto do good for patients
Confidentialityto respect the privacy
Ethicsa system of moral principles that guides behaviors
Fidelityto respect our words and duty to patients
Justiceto be fair, treat people equally
Nonmaleficenceto prevent harm to patients
Veracitytruthfulness
Although the concept of principles guiding right and wrong conduct is not
new to nursing, professional ethics has received increasing attention in
nursing circles. Gerontological nurses commonly face ethical questions
regarding the provision, scope, or cost of care for older adults. Many of
these questions arise in nurses’ daily practice. It is important for nurses to
understand both the ethics of the nursing profession and their own personal
ethics and to be aware of the ethical dilemmas facing gerontological nurses
today.
PHILOSOPHIES GUIDING ETHICAL

THINKING
The word ethics originated in ancient Greece—ethos means those beliefs
that guide life. Most current definitions of ethics revolve around the
concept of accepted standards of conduct and moral judgment. Basically,
ethics help determine right and wrong courses of action. As simple as this
sounds, different philosophies disagree about what constitutes right and
wrong; the following are some examples:
Utilitarianism. This philosophy holds that good acts are those from
which the greatest number of people will benefit and gain happiness.
Egoism. At the opposite pole from utilitarianism, egoism proposes that
an act is morally acceptable if it is of the greatest benefit to oneself and
that there is no reason to perform an act that benefits others unless one
will personally benefit from it as well.
Relativism. This philosophy can be referred to as situational ethics, in
that right and wrong are relative to the situation. Within relativism are
several subgroups of thinking. Some relativists believe that there can
be individual variation in what is ethically correct, whereas others feel
that the individual’s beliefs should conform to the overall beliefs of the
society for the given time and situation.
Absolutism. Under the theory of absolutism, there are specific truths to
guide actions. The truths can vary depending on a person’s beliefs; for
example, a Christian’s view may differ from an atheist’s view on
certain moral behaviors, and a person who supports a political view of
democracy may believe in truths different from those of a communist.
To illustrate the application of these four different philosophies,

consider the hypothetical situation of four poor old men who share a
household. One day, one of these men finds a lottery ticket in the mailbox
while checking the household’s mail. The ticket holds the winning number
for a million dollars. Ethically, does he owe his housemates any of the
winnings? A utilitarian would propose that he split the winnings with his
housemates because that would bring good to the greatest number of
people. An egoist would encourage him to keep the winnings because that
would do him the most good personally. A relativist might say that
normally he should keep the winnings, but because in this situation he will
have more money than he will need, he should share the winnings. An
absolutist who happens to be Christian may say that keeping the ticket is
morally wrong and an effort should be made to find the rightful owner.
Now consider the application of the philosophical approaches to the
issue of federal subsidies to older adults. A utilitarian could say that 14% of
the population should not use one third of the gross national product and
that the money instead should be equally allocated on a per capita basis. An
egoist would say that the individual old person should take whatever he
feels he needs, regardless of the impact on others. A relativist could say that
older people can use this proportion of the budget unless more is needed for
dependent children or defense, at which point it would no longer be right to
do so. Absolutists could hold various views depending on their belief
systems, ranging from giving the older population whatever they need
because of a moral responsibility to care for the sick and aged, to
withholding funds from the older population so that finances are available
to build the military and meet specific political goals.
Other philosophies guiding ethics exist, but the few that have been
briefly described demonstrate the diversity of approaches to ethical thinking
and reinforce the fact that determining right and wrong actions can be a
complicated endeavor.
KEY CONCEPT
Individuals can be guided by a wide range of ethical philosophies that
cause them to view the same situations in vastly different ways.
ETHICS IN NURSING

Professions such as nursing require a code of ethics on which practice can
be based and evaluated. A professional code of ethics is accepted by those
who practice the profession as the formal guidelines for their actions. For
example, the American Nurses Association (ANA) Code of Ethics for
Nurses offers ethics that outline the broad values of the profession.
(Information about the Code is available at
http://www.nursingworld.org/codeofethics.) The American Holistic Nurses’
Association has developed the Code of Ethics for Holistic Nursing that
provides guidance for nurses’ actions and responsibilities for self, others,
and the environment (the full document is available on their site at
http://www.ahna.org; search for “ethics”).
Nurses are also subject to ethical standards created outside of the
nursing profession. Federal, state, and local standards, in the form of
regulations, guide the nursing practice. In addition, various organizations
such as the Joint Commission and the American Healthcare Association
develop standards for specific practitioners and care settings. Individual
agencies, too, have philosophies, goals, and objectives that support a
specific level of nursing practice.
Most importantly, individual nurses possess values that they have
developed throughout their lives that will largely influence ethical thinking.
Ideally, a nurse’s individual value system meshes with that of the
profession, society, and employer; conflict can arise when value systems are
incompatible.
KEY CONCEPT
It is important for a nurse to understand his or her own values as conflict,
and distress can result when the nurse’s values differ from those of the
employer or population served.
Ethical Principles
Several ethical principles are used to guide health care, including the
following:
Beneficence: to do good for patients. This principle is based on the

belief that the education and experience of nurses enable them to make
sound decisions that serve patients’ best interests. Nurses are
challenged to take actions that are good for patients while not ignoring
patients’ desires. To override patients’ decisions and invoke
professional authority to take actions that nurses view as in patients’
best interests is viewed as paternalism and interferes with the freedom
and rights of patients.
Nonmaleficence: to prevent harm to patients. This principle could be
viewed as a subset of beneficence because the intent is ultimately to
take action that is good for patients. In addition to not directly
performing an act that causes harm, actions such as informing
management that staffing is inadequate to provide safe care support
nonmaleficence .
Justice: to be fair, treat people equally, and give patients the service
they need. At the foundation of this principle is the belief that patients
are entitled to services based on need, regardless of the ability to pay.
Scarce resources have challenged this concept of unrestricted access
and use of health care services.
Fidelity and veracity: fidelity means to respect our words and duty to
patients; veracity means truthfulness. This principle is central to all
nurse–patient interactions because the quality of this relationship
depends on trust and integrity. Older patients may have higher degrees
of vulnerability than do the younger adults and may be particularly
dependent on the truthfulness of their caregivers.
Autonomy: to respect patients’ freedoms, preferences, and rights.
Ensuring and protecting older patients’ right to provide informed
consent are consistent with this principle.
Confidentiality: to respect the privacy of patients. Patients often share
highly personal information with nurses and need to feel assured that
their trust will not be violated. In addition to respecting confidentiality
as being a morally sound principle, the Health Insurance Portability
and Accountability Act and other laws have afforded people the legal
right to privacy and consequences if this is violated.
Few nurses would argue with the value of these principles (Fig. 9-1). In
fact, practices that reinforce these principles are widely promoted, such as
ensuring that patients receive the care they need, respecting the rights of
patients to consent to or deny consent for treatment, preventing incompetent
staff from caring for patients, and following acceptable standards of
practice. Actual nursing practice is seldom simple, however, and situations
emerge that add new considerations to the application of moral principles to
patient care. Ethical dilemmas can emerge when other circumstances
interfere with the clear, basic application of ethical principles.
FIGURE 9-1 Nurses follow the principles of doing good,
treating people equally, honoring their word, and
respecting older adults’ rights.
POINT TO PONDER
How do you respond to and try to solve ethical dilemmas? If you are in
practice, do you accept different standards in practice from what you
would accept in your personal life? If so, why?
An issue that must be considered in nursing practice is that what may be
considered an ethical practice for some individuals may not be viewed as
such by others due to their cultural backgrounds. For instance, a nurse may
be a white, Protestant woman born in the United States who holds the
beliefs shown in the bulleted list below. The nurse may view these as sound
ethical beliefs and allow them to guide her practice. Although these beliefs
could be acceptable and appreciated by many individuals, they could
conflict with the beliefs of others; for example:
The belief that individuals have the right to make their own decisions
regardless of their sex and should be empowered to do so. In many
Amish, German, Greek, Haitian, Irish, and Puerto Rican families,
individuals discuss important decisions with family members and may
prefer to have the family involved in the decisions. Jewish individuals
may seek the advice of a rabbi. Some people may not want to discuss
issues and confront decision-making; for instance, many Filipinos,
Chinese, and Japanese view discussions of death as taboo.
Women are equal to men. In Arab, Iranian, Hindu, and some Italian
families, it is common for males to assume decision-making roles, and
women may yield their decision-making authority to them.
Prayer is a beneficial supplement to medical treatment. Prayer may
not be welcomed by patients who are agnostic or atheistic. Even
among persons who do believe in prayer, there may be differences in
the deity worshipped and method of prayer.
People have the right to have the confidentiality of their health
information protected, even from relatives. To individuals who view
family involvement in decision-making as natural and preferable, there
may be a desire to have health information shared with the family.
Nurses need to appreciate that ethical issues are influenced by culture.

Learning about a patient’s culture and preferences based on it are essential
to assuring actions do not inadvertently produce ethical conflicts. Also, it is
important for nurses to remember that not all individuals from the same
cultural group may share the same beliefs and practices, which further
reinforces the important of learning about individual preferences.
COMMUNICATION TIP
Older adults, especially when their function is compromised by
illness, may look to family members to make decisions for them. They
may accept the decisions others make on their behalf, even if these
decisions conflict with their own beliefs and desires.
If the nurse sees that others are making decisions for the older
adult that the person is competent of making independently, it is
beneficial to review the decision with the person to ensure that he or
she fully understands, present all options available, ask the person to
describe what is important to him or her in relation to the decision,
reinforce to the person that he or she has the right to make a decision
that is different from that of family members, and ensure that the
person is in agreement and comfortable with the decision. It is
beneficial to discuss with family members the importance and right of
the older relative to make his or her own decision, even if it conflicts
with what they think is best.
ETHICAL DILEMMAS FACING
GERONTOLOGICAL NURSES
Nursing practice involves many situations that could produce conflicts—
conflicts between nurses’ values and external systems affecting their
decisions and conflicts between the rights of patients and nurses’
responsibilities to those patients. Box 9-1 presents examples of such
dilemmas. These examples are typical of the decisions facing nurses every
day and for which there are no simple answers.
BOX 9-1 Examples of Ethical Dilemmas in

Gerontological Nursing Practice
While working in an outreach program to bring services to community-
based older adults, you meet Mr. Brooks, a 68-year-old homeless man.
Mr. Brooks asks your opinion about respiratory symptoms that he has
been experiencing over the past several months. He reports a chronic
cough, hemoptysis, and dyspnea. He appears thin and admits to having
lost weight. He states that he has smoked at least one pack of cigarettes
daily for over 50 years and has no intention of changing his smoking
habit. Although he is not cognitively impaired, he strongly resists efforts
to find him housing and arrange for medical evaluation and treatment.
You are convinced that without intervention, Mr. Brooks will not survive
much longer.
Do you respect Mr. Brooks’ right to make his own decisions about
his life, even if those decisions run contrary to what is best for his health
and well-being?
You are the new director of nursing for a nursing home and were
pleased to get the job because yours has become the sole source of
income for your family. Ten cases of diarrhea develop among the
residents, and you know that the regulations require that you report five
cases or more. You bring this to the attention of the medical director and
administrator, who direct you not to “cause trouble by putting the health
department on their backs.” The medical director assures you that the
problem is not serious and will pass in a few days. You know you should
notify the health department, but you also know that the administrator
fired the last nursing director for opposing him or her on a similar issue.
Do you allow a regulation to be violated or risk losing a job that you
may badly need?
Insurance coverage expires tomorrow for 76-year-old Mrs. Brady,
and the physician has written an order for her discharge. Because Mrs.
Brady continued to be weak and slightly confused, she was not able to be
instructed in the safe use of home oxygen and medication administration
during her hospitalization. Her 80-year-old husband, who is expected to
be her primary caregiver, is weak and in poor health himself. The social
worker tells you that arrangements have been made for a nurse to visit
the home daily but that the couple does not qualify for 24-hour home
care assistance. You and other nursing staff members firmly believe that
Mrs. Brady’s health will be in jeopardy if she is discharged tomorrow.
The physician tells you that you are probably right, but “the hospital
cannot be expected to eat the bills that Medicare does not want to pay.”
Do you increase the hospital’s financial risks by insisting that
nonreimbursed care be provided?
Seventy-nine–year-old Mr. Adams lies in his bed in a fetal position,
unresponsive except to deep painful stimuli. He has multiple pressure
ulcers, has recurrent infections, and must be fed with a nasogastric tube.
His wife and children express concern over the quality of his life and
state that Mr. Adams would never have wanted to survive in this state.
The children privately tell the multidisciplinary team that if their father’s
care expenses continue, their mother will be destitute, and they beg the
staff to remove the tube. The family expresses that they do not have the
emotional or financial resources to take the issue to court. The physician
is sympathetic, but states that he feels compelled to continue the feedings
and antibiotics because he does not condone euthanasia; however,
privately, the physician tells you that he or she will close his or her eyes
and keep quiet if you want to pull the tube without anyone knowing.
Do you exceed your authority and discontinue a life-sustaining
measure to grant the family’s request?
Mrs. Smith is dying of cancer and being cared for at home by her
husband. The couple has been married for 63 years and has never been
apart during that time. They are highly interdependent and each one’s
world revolves around the other’s. During your home nursing visit, the
couple openly discusses their plans with you. They tell you that they
have agreed that when Mrs. Smith’s pain becomes too severe to tolerate,
they will both ingest sufficient medication, which they have
accumulated, to kill themselves, and die peacefully in each other’s arms.
Do you ignore your responsibility to report suicidal intent to respect
a couple’s wish to end their lives together?
It is easy to say that nurses should always follow the regulations, adhere
to principles, and do what is best for the patient. But can nurses realistically
be expected to follow these guidelines 100% of the time? What if following
the rules means they may lose the income on which their families depend,
violate the rights of individuals to decide their own destinies, create
problems for coworkers or their employers, or cause them to be labeled
troublemakers? Is it alright to knowingly violate a regulation or law if no
real harm will result? Do nurses need to limit how much of an advocacy
role they can assume? Should nurses base their decisions on what is right
for themselves, their patients, or their employers? To whom are nurses
really most responsible and accountable?

Questions of ethics are not new to nursing. However, changes within the
profession and the entire health care delivery system have introduced new
areas of ethical dilemmas to nursing practice.
Expanded Role of Nurses

Nurses have gone beyond the confines of simply following doctors’ orders
and providing basic comfort and care. They now perform sophisticated
assessments, diagnose nursing problems, monitor and give complicated
treatments, use alternative modalities of care, and, particularly in geriatric
care settings, increasingly make independent judgments about patients’
clinical conditions. This wider scope of functions, combined with higher
salaries and greater status, has increased the accountability and
responsibility of nurses for the care of patients.
Medical Technology
Artificial organs, genetic screening, new drugs, computers, lasers,
ultrasound, and other innovations have increased the medical community’s
ability to diagnose and treat problems and to save lives that once would
have been given no hope. However, new problems have accompanied these
advances, such as determining on whom, when, and how this technology
should be used.
New Fiscal Constraints

In the past, the major concern of health care providers and agencies was to
provide quality services to help people maintain and restore health. Now,
there are competing and sometimes overriding concerns, including the
following: being cost-effective, minimizing bad debts, and developing
alternate sources of revenue. Patients’ needs are weighed against economic
survival, resulting in some difficult decisions. Further, in this era of rationed
care and scarce resources, questions are raised regarding the right of older
adults to expect a high quality and quantity of health and social services
while other groups lack basic assistance.
KEY CONCEPT
Increasingly, questions are raised regarding the right of older adults to
expect greater benefits than other members of the society.
Conflict of Interest
Nurses can face a variety of situations that present a conflict of interest.
Examples of this could include the following: a nurse, believing a resident’s
life could be extended with nasogastric feedings and antibiotic therapy,
feeling that a resident’s and family’s rejection of this care is inappropriate; a
patient’s physical therapy discontinued due to insurance restrictions and the
nurse knowing that the patient has the potential to make continued progress
with the therapy; and the nurse knowing the employer is intentionally
keeping staffing levels below what is needed but not objecting or
advocating for proper staffing because the nurse does not want to jeopardize
his or her position.
Greater Numbers of Older Adults

Entitlement programs and services for older persons had less impact when
only a small portion of the population was old, but with growing numbers
of people spending more years in old age and the increasing ratio of
dependent individuals to productive workers, society is beginning to feel
burdened. Although older adults’ problems and needs are more evident, the
ability and responsibility of society to support these needs are in question.
Assisted Suicide
The ANA has been clear in its objection to assisted suicide, believing that
nurses hastening a patient’s death is inconsistent with the basic
commitments of the nursing profession and violates public trust in the
profession (ANA Ethics Advisory Board, 2019). However, although
participating in a patient’s assisted suicide is unethical and inappropriate,
nurses may discuss options with terminally ill individuals who accept and
desire assisted suicide; nurses also have the right to conscientiously object
to being involved in aiding assisted suicide. The situation becomes even
more complicated by the fact that laws have been enacted in some states
(e.g., Hawaii, New Jersey, Maine, Oregon, Vermont, and Washington) to
allow terminally ill persons to end their lives with lethal medications, and
individuals have the right to refuse care under self-determination directives.
A few states that do not have laws supporting physician-assisted suicide
have allowed it through individual court decisions. Nurses may face the
dilemma of knowing that a competent patient is arranging an assisted
suicide and believing that they must intervene. Or, they may know that a
competent patient is arranging an assisted suicide, and while understanding
and respecting the patient’s decision, they feel they are violating
professional standards by not reporting it so that it may be halted.
POINT TO PONDER
Do you believe that gerontological nurses have an ethical responsibility
to advocate for older individuals by objecting to and bringing public
attention to policy and reimbursement decisions that are not in older
persons’ best interests?

Although guidelines exist, no solid answers can solve all of the ethical
dilemmas that nurses face. Nurses should, however, minimize their
struggles in making ethical decisions by using critical thinking and
employing the following measures:
Encourage patients to express their desires. Advise patients to express

their desires in advance directives, wills, and other legally binding
documents and advocate compliance with patients’ wishes. Box 9-2
offers suggestions on assisting patients in making decisions.
Identify significant others who impact and are impacted. Consider
family members, friends, and caregivers who are involved with the
patient and the situation, and their concerns and preferences.
Know yourself. The nurse should review his or her personal value
system. The influences of religion, cultural beliefs, and personal
experiences should be explored to understand one’s unique comfort
zone with specific ethical issues.
Read. Review the medical literature for discussions and case
experiences of other nurses to gain a wider perspective into the types
of ethical problems confronted within nursing and strategies for
managing them. Literature outside the field of nursing can help add
new facets to one’s thinking.
Discuss. In formal education programs or informal coffee breaks, talk
about issues with other health team members. Members of the clergy,
attorneys, ethicists, and others also can provide interesting
perspectives.
Form an ethics committee. Bring together various members of the
health team, clergy, attorneys, and lay persons to study ethical
problems within the specific care setting, clarify legal and regulatory
boundaries, develop policies, discuss ethical problems that surface, and
investigate charges of ethical misconduct.
Consult. Clinical ethics consultation takes the form of an ethics
committee or consultation provided by expert individuals or groups
(e.g., lawyers, philosophers, and clinicians who specialize in
bioethics). Clinical ethics consultants provide education, mediate
moral conflict, facilitate moral reflection, and advocate for patients
(the American Society for Bioethics and the Humanities Code of
Ethics and Professional Responsibilities for Healthcare Ethics
Consultants can be found at
https://asbh.org/uploads/ASBH_Code_of_Ethics.pdf).
Share. When faced with a difficult ethical decision, talk with others
and seek guidance and support.
Evaluate decisions. Assess the outcomes of the actions and whether
the same courses of action would be chosen in a similar situation in the
future. Even the worst decision holds some lessons.
BOX 9-2 Assisting Older Adults in Decision-

Making
Assure the person is competent to make decisions. Even if the
person has no diagnosis (e.g., dementia) that would interfere with
decision-making, the stress of a hospitalization and the effects of
medications or other treatments could alter the mental ability to
make competent decisions. Assess for alterations in mental status
that could influence competent decision-making. If competency is
in question, consult with the organization’s social worker or other
designated professional to have a surrogate properly appointed.
Document the assessment of factors influencing the ability to make
decisions, such as mental status, ability to express preferences,
mood, effects of medications, and family influence.
If the individual is competent to make decisions:
Offer explanations and information regarding treatment options to

increase the person’s understanding. Offer to include family
members or significant others in the discussion if the person
desires.
Ensure that the person understands the diagnosis, prognosis,
treatment options, and risks and benefits of various treatments.
Encourage the person to ask questions and express any concerns.
If there is question or confusion about procedures for which consent
is needed or has been granted, request that the provider who will
perform the procedure meet with the person to discuss the issue.
Ensure that the person is not being coerced into any decision or
feeling intimidated to state a refusal to give consent.
Recognize that ability to make competent decisions can fluctuate
(e.g., due to medications, pain), and ensure that explanations are
provided and decisions made during times of lucidity.
Document all assessment findings, explanations given, the person’s
expressed preferences and concerns, and other relevant information.
Avoid having your own personal views influence a person’s
decisions.
CONSIDER THIS CASE

Seventy-nine-year-old Mr. J has been
diagnosed with a rare liver cancer. The oncologist informs Mr. J that
although he is willing to attempt a round of chemotherapy, no treatment
has been effective in extending life for more than a few months for this
aggressive type of cancer. Mr. J and his 66-year-old wife are devastated by
this information and look to the Internet for help. They read testimonials
of patients who have had similar liver cancers whose lives allegedly were
extended for several years with an alternative treatment offered by a
hospital in Germany. They make contact with the hospital and learn that
Mr. J qualifies for their treatment, which consists of a 2-week-long stay at
the hospital in Germany, every 2 months. Each of the hospitalizations
costs $25,000 plus the couple’s travel expenses. The couple has no savings
but owns a very modest house; they have no children. The couple
discusses this option with the oncologist, who discourages the alternative
treatment, stating, “Your time and money would be better spent in
enjoying the remaining time you have together and making preparations
for Mr. J’s declining health and ultimate death.” Despite the physician’s
discouraging remarks, Mr. J wants to mortgage the house to pay for the
alternative treatment. Mrs. J wants to help her husband extend his life but
is concerned that she will face the prospect of losing the house or being
required to pay off the mortgage on her limited Social Security check long
after Mr. J dies. She is not comfortable with the idea, but feels that if she
voices her concerns, her husband, friends, and family will consider her
uncaring.
THINK CRITICALLY
1. Does Mr. J have the right to deplete the couple’s resources for a
questionable treatment that may only extend his life for a few
months?
2. Does Mrs. J have the right to oppose this plan?
3. Does Mr. J’s physician have the right to dash Mr. J’s hopes?
4. How could you assist the couple?
Gerontological nursing holds its share of ethical questions. Should

resources be spent for a heart transplant for an octogenarian? Should an
affluent child rather than public funds pay for a parent’s care? How much
sacrifice must a family endure to care for a relative at home? How much
compromise in care can nurses accept to keep an agency’s budget healthy?
Nurses must be active participants in the process of developing ethically
sound policies and practices affecting the care of older adults. The choice
between being a leader and an ostrich in this arena can significantly
determine the future status of gerontological nursing practice.
Decreased Autonomy in Community-Dwelling

Older Adults
Source: Sanchez-Garcia, S., Garcia-Pena, C., Moreno-Tamavo, K., &
Canti-Quintanilla, G. R. (2019). Clinical Interventions in Aging, 14(10),
2041–2053.
Autonomy plays an important role in the lives of older adults and
contributes to good health and longevity. Although reduced physical and
cognitive health can hinder independent decision-making, there is the risk
that the presence of health conditions can cause health professionals and
family members to assume older adults lack the ability for autonomous
decision-making, even when they are competent to do so. This study aimed
to explore the characteristics that could cause the perception of low
autonomy among community-dwelling older adults.
The researchers conducted a cross-sectional study involving 1,252
individuals over age 60. Using standardized tests, the researchers performed
assessments of cognition, spirituality, activities of daily life, mood, and
health perception. They used the section of the World Health Organization
Quality of Life of Older Adults tool pertaining to autonomy.
The researchers found that community-dwelling older adults had a
decreased perception of autonomy. Factors associated with low levels of
autonomy were limited education, a lack of spirituality, low social support,
cognitive impairment, depression, and limitations in the ability to carry out
activities of daily living.
Older adults with reduced perceptions of autonomy are more likely to
not participate in their decision-making to the fullest extent to which they
are capable. It is important for nurses to promote maximum decision-
making in older persons. During the assessment, the nurse should explore
factors that can potentially limit autonomy in decision-making and develop
plans to address them. Older adults who unnecessarily defer to others for
decision-making can be encouraged to make their own decisions; the
establishment of trust-building relationships with older persons can
facilitate such discussions. If nurses observe others making decisions for an
older adult, they should assure those individuals that the older adult has the
necessary information to make decisions, and nurses should facilitate the
older adult’s expression of preference. Advocating for individuals to display
maximum autonomy is an important responsibility of gerontological nurses.
PRACTICE REALITIES
A citizen action group is concerned about taxes and is developing a list of
recommendations to offer its congressional representatives. Among the
recommendations is one to limit Medicaid- and Medicare-reimbursed
expensive surgeries (e.g., hip replacements and organ transplant) to only
persons under the age of 80. The rationale is that the limited funds are best
used in younger persons who have more years left of life.
Although you understand that health care dollars are limited and
appreciate the impact of growing tax burdens, as a gerontological nurse you
feel a responsibility to advocate for the rights of older adults to have the
same services available as other age groups.
How would you react to the citizens’ group?

1. What factors have influenced your personal ethics?
2. Discuss the dilemmas arising from the following situations:
Having a terminally ill patient confide plans to commit suicide

Being instructed to discharge a patient whose care is no longer being
reimbursed while knowing that the patient is not ready for discharge
Having to terminate a nursing assistant for attendance problems,
knowing that she is the sole wage earner in her family
Being asked by a senior citizen group to support its position of
converting a local playground into a senior citizen center
Learning of an insurer’s proposed policy of not reimbursing for
dialysis and organ transplants for persons over 75 years of age
Chapter Summary
Ethics are beliefs that guide life and assist in determining the right course of
action to take. Philosophical differences can cause variation in the way
individuals view right and wrong. Some philosophies influencing ethical
decision-making include utilitarianism, egoism, relativism, and absolutism.
In addition to personal ethics, nurses’ ethical decision-making is influenced
by codes of ethics developed by professional associations and regulatory
standards.
Ethical principles that are used in nursing practice include beneficence,
nonmaleficence, justice , fidelity and veracity, autonomy, and
confidentiality. Nurses need to appreciate that patients’ cultural
backgrounds can influence ethics for patients. Nurses need to be sensitive to
the reality that the “right” action according to their belief may be in conflict
with that which is considered “right” within some patients’ cultures.
Nurses may face ethical dilemmas in their daily work. These dilemmas
can be compounded by changes within the profession and the entire health
care system such as the expanded role of nurses, the use of medical
technology, new fiscal constraints, conflicts of interest, growing numbers of
older individuals, and growing interest in assisted suicide.
To foster ethical decision-making, it is important for nurses to
encourage patients to express their desires and involve significant others
who are in the patients’ lives as appropriate, get in touch with personal
values, continue to read and learn about ethical decision-making, discuss
and consult with others, form an ethics committee, and evaluate decisions.
Online Resources
American Nurses Association, Center for Ethics and Human Rights
http://www.nursingworld.org/ethics
American Society of Bioethics and Humanities
http://asbh.org
Reference
ANA Ethics Advisory Board. (2019). ANA position statement: The nurse’s role when a patient
requests medical aid in dying. Online Journal of Issues in Nursing, 24 (3). doi:
10.3912/OJIN.Vol24No03PoSCol02.
CHAPTER 10
Continuum of Care in Gerontological
Nursing
Chapter Outline
Services in the Continuum of Care for Older Adults
Matching Services to Needs
Settings and Roles for Gerontological Nurses
LEARNING OBJECTIVES
1. Describe the continuum of services available to older adults.

2. Discuss factors that influence service selection for older adults.
3. Describe various practice settings for gerontological nurses.
4. List major functions of gerontological nurses.
TERMS TO KNOW
Adult day servicescenters that provide health and social services for a
portion of the day to persons with moderate physical or mental
disabilities and give respite to their caregivers
Assisted livingresidential care for persons who do not require nursing
home level services but who cannot fulfill all personal care and/or
health care needs independently are referred to as assisted living
communities, residential care facilities, personal care, and boarding
homes
Case managementservices provided by registered nurses or social
workers who assess an individual’s needs, identify appropriate services,
and help the person obtain and coordinate these services in the
community
Continuing care retirement communityan option for long-term care that
affords older adults the ability to remain in the same place as their care
needs change in return for a monthly fee and, in most circumstances, an
entry fee
Hospiceservices that provide support and palliative care to dying
individuals and their families in the home or an institutional setting
Nursing homefacility that provides 24-hour supervision and nursing care
to persons with physical or mental conditions who are unable to be
cared for in the community
Respiteservices to provide short-term care to individuals, thereby offering
their caregiver’s short-term relief from their caregiving responsibilities
The effects of a graying population are all around us. The media report the
spiraling costs of Medicare and Social Security. Banks advertise reverse
annuity mortgage programs aimed at helping older adults remain in their
homes. A new continuing care retirement community (CCRC) is
constructed. A major corporation initiates an adult day care program. A
family leave law is passed. The local hospital issues a circular informing the
community of new services for senior citizens. A nearby church sponsors a
caregiver support group.
One does not need to be a nurse or nursing student to be aware of the
impact of older adults on all segments of society. We are increasingly aware
that older adults are major consumers of virtually all health care services.
Consider the following:
Growing numbers of Americans are interested in wellness programs

that help them stay youthful, active, and healthy.
The prevalence of mental health problems increases with age.
Chronic diseases occur at a rate four times greater in old age than at
other ages, with 80% of older adults having at least one chronic
condition (Centers for Disease Control and Prevention, 2019).
A majority of users of inpatient long-term care services (e.g., nursing
home , residential care, hospice ) are aged 65 and over (National
Center for Health Statistics, 2019).
Most beds in acute medical hospitals are filled by older patients.
Opioid-related hospitalizations have increased fastest among persons
over age 65 years as compared with all other age groups (Healthcare
Cost and Utilization Project, 2018).
Older adults are the most significant users of home health services.
Whether working in nursing homes, health maintenance organizations

(HMOs), outpatient surgical centers, hospice programs, rehabilitation units,
or private practice, nurses are likely to be involved in gerontological
nursing.
The diversity of the aging population and the complexity of needs it
presents demands a wide range of nursing services. A continuum of care,
including services for older adults who are the most independent and well at
one end and the most dependent and ill at the other, is essential to meet the
complex and changing needs presented by the older population.
SERVICES IN THE CONTINUUM OF

CARE FOR OLDER ADULTS
The continuum of care consists of supportive and preventive services,
partial and intermittent care services, and complete and continuous care
services (Fig. 10-1). This continuum includes opportunities for community-
based services, institution-based services, or a combination of both.
Complementary and alternative services may also be included in the
continuum.
FIGURE 10-1 Continuum of care services for older
adults.
To plan care for older adults effectively, nurses must be familiar with
the various forms of care available. In fact, visiting various agencies to
learn about their services firsthand can prove beneficial for the
gerontological nurse. Although services can vary from one area to another,
some general examples are described in the sections that follow.

Most older adults reside in the community and function with minimal or no
formal assistance. Many of them adjust their lives to accommodate changes
commonly experienced with aging; some manage complex care demands.
Nurses are challenged to help older adults maintain independence, prevent
risks to health and well-being, establish meaningful lifestyles, and develop
self-care strategies for health and medical needs.
Supportive and preventive services support independent individuals in
maintaining their self-care capacity so that they can avoid physical,
emotional, social, and spiritual problems. In this category of services,
nurses most likely will be involved with the following:
Identifying service needs

Referring older adults to appropriate services
Supporting and coordinating services
Local offices on aging, commissions on retirement education, libraries,
and health departments usually provide assistance to older persons in
learning about available services. Nurses should encourage older persons to
use these resources for any questions and assistance needed. Local
departments of aging publish resources that are available in a specific
community. In addition, the Administration on Aging hosts a Web site that
is a gateway to a wide range of information and services for older adults
and their families; this can be accessed through
https://eldercare.acl.gov/Public/About/Aging_Network/AoA.aspx.
Examples of supportive and preventive services for community-based older
adults are described below.
KEY CONCEPT
When working with community-based older adults, nurses focus on
maintaining independence, preventing risks to health and well-being,
establishing meaningful lifestyles, and developing self-care strategies for
health and medical needs.
Financial Services
The Social Security Administration may be able to help older persons
obtain retirement income, disability benefits, supplemental security income,
and Medicare or other health insurances. The district office of the Social
Security Administration can provide direct assistance and information. The
Department of Veterans Affairs (VA) can provide financial aid to older
veterans and their families; interested persons should be directed to the
local VA office. Various communities offer discounts to senior citizens at
department stores, pharmacies, theaters, concerts, restaurants, and
transportation services. Lists of discounts may be obtained from the local
offices on aging.
Many banks offer free checking accounts and other special services to
senior citizens. By completing a direct deposit form at their bank, older
adults can have the Social Security Administration deposit Social Security
and Supplemental Security Income checks directly to the bank; likewise,
pension checks can be deposited directly into checking accounts. This
service saves older adults from having to travel to the bank and serves as a
protection from crime. Reverse annuity mortgages can be arranged through
banking institutions to allow older homeowners to use the equity in their
homes to remain in the community. It is advisable for older persons to
explore details of such services with their individual financial institution.
Financial assistance is also available for burial and funeral expenses.
For instance, wartime veterans are eligible for some assistance from the VA.
Also, the Social Security Administration provides a small payment for
burial expenses to those who have been insured by that program. Local
offices of these administrations can be contacted for information; funeral
directors are also a good source of information about these benefits. Finally,
social service agencies and religious organizations often provide assistance
for persons with insufficient funds to pay for burial expenses.
COMMUNICATION TIP
Discussing finances can be difficult for some older adults. This can be
due to their embarrassment at experiencing financial problems,
concern related to protecting their assets, or desire to avoid having
family members and others learn about their financial status. Nurses
who have established a trusting relationship with older adults may be
in a good position to introduce discussions of finances. This can
include assisting in identifying sources of aid to ease their financial
burden, suggesting how to introduce topics for discussion (e.g.,
funeral arrangements, durable power of attorney, desires for
distribution of assets) with family members, and providing referrals to
professionals who can assist with financial planning and the
development of wills.
Employment
If older adults desire to work, nurses can refer them to employment
services. State employment services and the Over 60 Counseling &
Employment Service conduct programs that provide employment
counseling and job placement. Various states also have foster grandparent
programs, older businessperson associations, and senior aide projects. Local
offices on aging can direct older persons to employment programs and
opportunities in their community.
Nutrition
The departments of social services can supply information about and
applications for the Supplemental Nutrition Assistance Program (SNAP) to
help older persons purchase food within the constraints of their budget.
These departments may also provide grocery shopping services and
nutrition classes. Many senior citizen clubs and religious organizations offer
lunch programs that combine socialization with nutritious meals. The local
office or department on aging or the health department can direct persons to
the sites of such programs.
Housing
Local social service agencies and departments of housing and community
development can assist older persons in locating adequate housing at an
affordable cost. These agencies also may be able to direct the older
homeowner to resources to assist in home repairs and provide information
regarding property tax discounts. A variety of CCRCs (Box 10-1), villages,
mobile home parks, and apartment complexes, specifically designed for
older persons, are available throughout the United States. Some of these
housing complexes include special security patrols, transportation services,
health programs, recreational activities, and architectural adjustments (e.g.,
low cabinets, grab bars in bathrooms, tinted windows, slopes instead of
stairs, and emergency call bells). Some of these housing options require a
“buy-in fee” or purchase price, a monthly fee, or both. The older person
exploring retirement housing should be advised that sound facts are more
important to decision-making than exciting promises. Visits to the housing
complex and a full investigation of benefits and costs before making a
contractual commitment are essential.
BOX 10-1 Continuing Care Retirement

Communities
CCRCs offer a continuum of services in one location to provide various
levels of housing and services to meet an older adult’s changing needs.
Typically, people pay an entrance fee and a monthly fee, with an
understanding that they will be able to have their needs provided by the
community for the remainder of their lives. Contracts can vary and
consist of a set fee for unlimited services, a set fee for time-limited
services, or additional charges if assisted living , home health, or skilled
nursing services are required.
Healthy individuals can enter and live in independent housing units,
which could consist of single-family homes, apartments, or
condominiums. Housekeeping, laundry, meals, transportation, social
activities, and health services can be provided for additional fees.
As individuals require more assistance, they can receive assistance
with personal care in their own housing unit or move to the assisted
living community or nursing home section of the CCRC.
Entrance fees, conditions for refund of entrance fees, monthly costs,
services available, and terms of contracts vary among CCRCs, so it is
useful for older adults interested in CCRCs to visit and compare several
and carefully review the contracts.
Health Care
Nurses can encourage older adults to engage in preventive health practices
to avoid illness and detect health problems at an early stage. Health services
for older adults are provided by health departments, HMOs, private
practitioners, and hospital outpatient services. In addition to health services,
these providers may help older adults obtain transportation and financial
assistance for their health care. Older individuals should inquire about such
services at their nearest health care office.
Social Support and Activities

Churches, synagogues, and mosques offer not only a place of worship but
also a community that can provide tremendous fellowship, support, and
assistance to persons of all ages. Many religious groups offer health and
social services such as congregate eating programs, nursing homes, home
visitation, and chore assistance. In many circumstances, recipients of
services need not be members of the religious group. Increasing numbers of
faith communities employ nurses to assist with members’ health and social
needs, and Faith Community Nursing is a blossoming specialty. Individual
churches and synagogues or the mother organization (e.g., Associated
Jewish Charities and Catholic Charities) should be contacted for
information.
Bureaus of recreation and other groups may also sponsor clubs and
activities expressly for senior citizens. Local commissions or offices on
aging can provide information related to the availability of such programs,
their activities, schedules, and persons to contact for details. Local chapters
of the American Association of Retired Persons (AARP) can provide
valuable information on services that keep older persons active and
independent, ranging from creative leisure endeavors at home to discount
travel opportunities. Information about leisure pursuits is just one of the
many services the AARP provides. Finally, art museums, libraries, theaters,
concert halls, restaurants, and travel agencies should be contacted for
special programs offered to senior citizens.
Volunteer Work
Nurses can also encourage older adults to participate in volunteer activities.
The wealth of knowledge and experience possessed by older persons makes
them especially suited for volunteer work. Not only do older volunteers
provide valuable services to others, but they may also achieve a sense of
self-worth from their contributions to society. Communities offer numerous
opportunities for senior volunteers in hospitals, nursing homes,
organizations, schools, and other sites. Older persons should be encouraged
to inquire about volunteer opportunities at the agency in which they are
interested in serving. Frequently, agencies without a formal volunteer
program are able to use a volunteer’s service if contacted. National
programs also provide meaningful volunteer services in which older
persons can participate. The American Red Cross, Service Corps of Retired
Executives, and Retired and Senior Volunteer Program are a few such
programs. Local offices of these programs should be consulted for details.
Education
Some public schools offer literacy, high school equivalency, vocational, and
personal interest courses for older adults. Many colleges have free tuition
for older persons. Individual schools should be contacted for more details.
Counseling
Financial problems, the need to locate new housing, strained family
relationships, widowhood, adjustment to a chronic illness, and retirement
are among the situations that may necessitate professional counseling.
Local social service agencies, religious organizations, and private therapists
are among the resources that offer assistance.
Consumer Affairs
Senior adults are frequent victims of unscrupulous people who profit by
making convincing but invalid promises. It is important for older adults to
investigate cure-alls, vacation programs, and get-rich-quick schemes before
investing their funds. Local offices of the Better Business Bureau and
consumer protection agencies provide useful information to prevent fraud
and deception and offer counseling if problems do arise.
Legal and Tax Services

Local legal aid bureaus and lawyer referral services of the Bar Association
may help older adults obtain competent legal assistance at a nominal cost.
The Internal Revenue Service can help older people prepare federal tax
returns, and the state comptroller’s office can assist with state tax returns;
local offices should be contacted for additional information. Various
colleges and law schools should be investigated for free legal and tax
services offered to senior citizens.
Transportation
Older persons often receive discounts for bus, taxicab, subway, and train
services; individual agencies should be contacted for more information.
Commissions or offices on aging, health and social services departments,
and local chapters of the American Red Cross may be able to direct persons
to services accommodating wheelchairs and other special needs. Various
health and medical facilities provide transportation for persons using their
services; individual facilities should be explored for specific details.
Personal Emergency Response Systems

A Personal Emergency Response System (PERS), also called a Medical
Emergency Response System, is a small battery-operated transmitter device
a person wears (around the next, on a belt or wristband, or in a pocket) that
can be used to signal for help by pressing a button. The transmitter then
sends a signal that dials an emergency response center. When signaled, the
response center contacts the person or predesignated contacts. A variety of
companies offer this service, and in most cases, it is not covered by health
insurance programs. The local Area Agency on Aging can assist in advising
what systems are available in a specific area.
Shopping at Home
Persons who are homebound, who are geographically isolated from
services, or who have busy schedules may find it useful to shop at home
through mail-order catalogs, home-shopping services on television, and the
Internet. Shopping by mail has a long tradition, and along with its newest
sibling, Internet shopping reduces the inconveniences and risks associated
with traveling to a shopping district, maneuvering in stores, handling large
sums of money in public, and carrying packages. The shipping and handling
charges may be no greater than transportation costs, not to mention the
energy expended in direct shopping.
CONSIDER THIS CASE

Mrs. Como, age 78, lives alone and has
managed independently until last month, when she began demonstrating
periods of dizziness, weakness, and confusion. Last week, she had an
accident in which she ran her car into a parked car; she reported to her
daughter that this happened because she “couldn’t figure out which pedal
was the brake.” Her daughter and son, concerned with the changes they
are witnessing in their mother, take Mrs. Como to her physician for an
examination. It is determined that Mrs. Como has congestive heart failure,
and she is admitted to the hospital for treatment.
Mrs. Como is successfully treated and prepared for discharge. Mrs.
Como feels insecure returning to her own home and indicates that she
thinks it may be best if she can live with one of her children, who live in
the same city she does. Mrs. Como’s son is adamant that due to his work
schedule, he cannot have his mother live with him. Although her daughter
has several children at home, works part-time, and has a busy life, she
feels that she can’t turn her mother away.
THINK CRITICALLY
1. What factors need to be considered in developing Mrs. Como’s
discharge plan?
2. What are the benefits and risks of the plan for Mrs. Como to live with
her daughter?
3. What services could be of benefit to Mrs. Como after discharge?
4. Describe the approach that would be effective in discussing discharge
plans with Mrs. Como and her children.
Additionally, many libraries have a service in which books and tapes

can be borrowed by mail; older persons should be encouraged to inquire
about such services at their local branch. The Internet offers many online
books and publications, many of which are free. The U.S. Postal Service
provides a service for a nominal fee in which stamps can be ordered by mail
or Internet; order blanks for stamps by mail can be obtained by contacting
the local postal station or postal carrier or visiting www.USPS.com.

Partial and intermittent care services provide assistance to individuals with
a partial limitation in self-care capacity or a therapeutic demand that
requires occasional assistance. Because of either the degree of the self-care
limitation or the complexity of the therapeutic action required, the
individual could be at risk for new or a worsening of existing physical,
emotional, and social problems if some assistance were not provided at
periodic intervals. These services can be provided in community or
institutional settings.
Assistance With Chores

Social service agencies, health departments, private homemaker agencies,
and faith communities have services for older persons that help them
remain in their homes and maintain independence. These services include
light housekeeping, minor repairs, errands, and shopping. Local agencies
and programs should be contacted for specific information.
Home-Delivered Meals
Persons unable to shop and prepare meals independently may benefit from
having meals delivered to their homes. Such a service not only facilitates
good nutrition but also provides an opportunity for social contact. Meals on
Wheels is the most popularly known program for home delivery of meals,
although various community groups provide a similar service. If a local
Meals on Wheels is unavailable, departments of social services, health
departments, and commissions or offices on aging should be consulted for
alternative programs.
Home Monitoring
Some hospitals, nursing homes, and commercial agencies provide home
monitoring systems, whereby the older adult wears a small remote alarm
that can be pressed in the event of a fall or other emergency. The alarm
triggers a central monitoring station to call designated contact persons or
the police to assist the individual. This type of service can be located by
calling the local agency on aging or looking in the telephone directory
under listings such as Medical Alarms.
A growing array of telemanagement technologies is affording the
opportunity for patients to have vital signs, blood glucose levels, and other
physiological measurements communicated from the home to providers.
Tracking systems and sensors can enable family members or caregivers to
monitor patients’ activity in their homes from a distance. Two-way audio
and video devices allow patients to interact with their providers from their
homes. Devices can be used to signal patients when to take medications and
perform other tasks. Medication administration systems exist whereby
family members and caregivers in another location can be informed if a
patient has not taken drugs as scheduled. An Internet search of home care
and patient care technology vendors will yield many suppliers of
technological aids for home care.
Telephone Reassurance
Older adults who are homebound, disabled, or lonely may benefit from a
telephone reassurance program. Those who participate in the program
receive a daily telephone call—usually at a mutually agreed on time—to
provide them with social contact and ensure that they are safe and well.
Local chapters of the American Red Cross and other health or social service
agencies should be consulted for telephone reassurance programs that they
may conduct.
Home Health Care

Home health care provides nursing and other therapies in individuals’
homes. Visiting nurse associations have a long reputation of providing care
in the home and are able to help many older persons remain in their homes
rather than enter an institution. Programs vary, and services can include
bedside nursing, home health aides, physical therapy, health education,
family counseling, and medical services. Medicare is limited to skilled
home care, which means that the person must:
Be homebound
Have services ordered by a primary care provider
Require skilled nursing or rehabilitative services
Need intermittent but not full-time care
During the 1970s and the decades that followed, home health services
significantly grew due to the enactment of the Older American’s Act and
Title XX Social Services Act in 1975 that provided federal funds for home-
based services and the Federal Health Services Program that gave grants for
the establishment and expansion of these services. By the 1990s, home care
became the fastest growing component of Medicare and the rising costs
influenced Congress to place limitations on home care benefits for
Medicare recipients as part of the Balanced Budget Act of 1997. At this
same time, in an effort to control the rising costs of nursing home care on
their Medicaid budgets, states began to develop more home care services as
an alternative to nursing home care.
KEY CONCEPT
The changes in home health care demonstrate the impact that
government funds can have on the availability of services to older adults.
At present, Medicare covers skilled nursing care but not long-term
nonskilled care. States have various Medicaid programs to assist in
nonskilled home care; private agencies also provide these services.
In addition to Medicare, the VA, Medicaid, and private insurers provide

reimbursement for home health services, although the conditions and length
of coverage vary; specific coverage should be reviewed with the insurer.
These programs can be found through health departments, in telephone
directories, or through social workers who assist with discharge planning.
Foster Care and Group Homes

Adult foster care and group home programs offer services to individuals
who are capable of self-care but who require supervision to protect them
from harm. Older persons placed in these homes may need someone to
direct their self-care activities (e.g., remind them to bathe and dress and
encourage and provide good nutrition); they may also need someone to
oversee their judgments (e.g., financial management). Foster care and group
living can serve as short- or long-term alternatives to institutionalization for
older persons unable to manage independently in the community. The local
department of social services can supply details about these programs.
Adult Day Services

Adult day services programs have been a growing component of
community-based, long-term care, currently numbering approximately
5,000 centers in the United States (National Adult Day Services
Association, 2019). These centers provide health and social services to
persons with moderate physical or mental disabilities and give respite to
their caregivers. Participants attend the program for a portion of the day and
enjoy a safe, pleasant, therapeutic environment under the supervision of
qualified personnel (Fig. 10-2). The programs attempt to maximize the
existing self-care capacity of participants while preventing further
limitations. Although the primary focus is social and recreational, there
usually is some health component to these programs, such as health
screening, supervision of medication administration, and monitoring of
health conditions. Rest periods and meals accompany the planned
therapeutic activities. Transportation to the site is provided, usually by
vehicles equipped to accommodate wheelchairs and persons with other
special needs.
FIGURE 10-2 Adult day care centers provide
opportunities for a variety of recreational activities.
In addition to helping older persons avoid further limitations and

institutionalization, day services programs are extremely beneficial to the
families of participants. Families interested in caring for their older relatives
may be able to continue their routine lifestyle (e.g., maintaining a job and
raising small children), knowing that they can have respite from their
caregiving responsibilities for a portion of the day while the older person is
cared for and safe.
Adult day services programs are sponsored by public agencies,
religious organizations, and private groups, with one third being
freestanding and the remaining ones affiliated with a larger parent
organization; each varies in schedule, activities, costs, and program focus.
The local telephone directory or information and referral service, as well as
the National Adult Day Services Association, can provide information on
programs in specific communities.
Adult day services provide health and social services to persons with
moderate physical or mental disabilities who need some supervision and
assistance with activities of daily living. A primary focus of these
programs is to give respite to caregivers.
Day Treatment and Day Hospital Programs

Day treatment and day hospital programs offer social and health services
with a primary focus on the latter. Assistance is provided with self-care
activities (e.g., bathing and feeding) and therapeutic needs (e.g., medication
administration, wound dressing, physical therapy, and psychotherapy).
Physicians, nurses, occupational therapists, physical therapists,
psychologists, and psychiatrists are among the care providers affiliated with
programs for day treatment. Like adult day services programs, geriatric day
treatment or day hospital programs usually provide transportation to and
from the program. Sponsored by hospitals, nursing homes, or other
agencies, these programs can be used as alternatives to hospitalization and
nursing home admission and can facilitate earlier discharge from these care
settings. Many of these programs focus on the care of persons with
psychiatric conditions. The local commission or office on aging can guide
persons to programs for day treatment or day hospitals in their community.
Assisted Living
Assisted living supplements independent living with special services that
maximize an individual’s capacity for self-care. Terminology used to
describe assisted living can fall under the categories of residential care
facilities, personal care, and boarding homes; different states use different
regulatory designations. The housing unit is adjusted to meet the needs of
older or disabled persons (e.g., wide doorways, low cabinets, grab bars in
bathroom, and call-for-help light). A guard, hostess, or resident screens and
greets visitors in the lobby. Various degrees of personal care assistance may
be provided. Residents are encouraged to develop mutual support systems;
one example is a system in which residents check on one another every
morning to see if anyone needs help. Tenant councils may determine
policies for the facility. Some facilities have a health professional on call or
on duty during certain hours; recognizing the unique health care needs in
this setting that can be appropriately addressed by nurses, nursing in
assisted living communities is a developing specialty. Social programs and
communal meals may also be available. State health department regulatory
agencies and the local office of the Department of Housing and Urban
Development may be able to direct interested persons to such facilities.
Respite Care
A variety of services can be utilized to provide short-term relief to
caregivers from their caregiving responsibilities. The services depend on
the need, status of the patient, and funds. For example, private home health
aides/companions or nurses can be hired to live in or occasionally visit the
older person while the caregiver is away; short-term admissions to assistive
living communities or nursing homes can provide respite when the person’s
caregiving demands and/or need for supervision is 24/7.
Health Ministry and Parish Nurse Programs

Many churches and synagogues have programs to assist older adults and
their caregivers such as support groups, health education classes,
counseling, housekeeping and home maintenance assistance, meals, and
home nursing visits. Many nurses are volunteers in these programs and
some are paid to serve in these roles. These services are ideal ways to
integrate health services with one’s faith. As services offered vary, nurses
should contact the church or synagogue of the patient, or if the patient is not
a member of one a local religious organization representing the patient’s
faith, to learn of the availability of services.
KEY CONCEPT
The American Nurses Association has recognized parish nursing as a
specialty and in collaboration with the Health Ministries Association
published the Faith Community Nursing: Scope and Standards of
Practice.
Care and Case Management

The identification of needs, location and coordination of services, and
maintenance of an independent lifestyle can be tremendous challenges for
older persons with chronic health problems. In response to these challenges,
the field of geriatric care and case management has developed.
Care and case managers most often are registered nurses or social
workers who assess an individual’s needs, identify appropriate services, and
help the person obtain and coordinate these services. Such services include
medical care, home health services, socialization programs, financial
planning and management, and housing. By coordinating care and services,
geriatric care and case managers assist older persons in remaining
independent in the community for as long as possible. The services of care
and case managers often provide peace of mind to family members who are
unable to be involved with their older family members on a daily basis.
As a system of credentials within this field has surfaced, there is greater
distinction between care management and case management. Both of these
disciplines perform some type of assessment, develop plans, help people
implement and coordinate services, and evaluate care. A distinguishing
difference between the two, however, is that care management is a long-
term relationship that could endure through multiple episodes of care (e.g.,
when a family contracts with a care manager to oversee the care of a
relative on a long-term basis), whereas case management usually focuses on
needs during a specific episode of care (e.g., from hospitalization through
rehabilitation for a hip fracture). Case management is viewed as a means to
control health care costs and may emphasize services for cost containment;
care management may include case management in addition to services
unrelated to health care.
Social workers, local information and referral services, and the Aging
Life Care Association can provide assistance in locating care and case
managers.
KEY CONCEPT
The American Nurses Association has found professional nurses to be
excellent case managers because of their knowledge and skills training,
their ability to deliver care that includes both physical and sociocultural
components, their familiarity with the process of services referral, and
the parallels between the nursing process and the process of case
management.
Program of All-Inclusive Care for the Elderly

Program of All-Inclusive Care for the Elderly (PACE) is a program that
enables persons age 55 or older who are eligible for nursing home care to
have all of their medical, social, and long-term care services provided in
their homes in the community. It is a joint Medicare and Medicaid program
available in states that have chosen to include it in their Medicaid programs.
Individuals can find out if there is a PACE program in their area by calling
their state Medicaid office or visiting their site.
Hospice
Although hospice care is listed here under partial and intermittent care
services, it can also be included under complete and continuous care
services. This is because the nature of the patient’s needs determines the
level at which this service is provided.
Rather than a site of care, hospice is a philosophy of caring for dying
individuals. Hospice provides support and palliative care to patients and
their families. Typically, an interdisciplinary team helps patients and
families meet physical, emotional, social, and spiritual needs. The focus is
on the quality of remaining life rather than life extension. Survivor support
is also an important component of hospice care. Although hospice programs
can exist within an institutional setting, most hospice care is provided in the
home. Insurers vary in the conditions that must be met for reimbursement of
hospice services; individual insurers should be consulted for specific
information. Health care and social service agencies can be consulted for
information about hospice programs in specific communities.

At the far end of the continuum of care are services that provide regular or
continuous assistance to individuals with some limitation in self-care
capacity whose therapeutic needs require 24-hour supervision by a health
care professional.
Hospital Care
Hospital care for older persons may be required when diagnostic procedures
and therapeutic actions indicate a need for specialized technologies or
frequent monitoring. Older adults can be patients of virtually all acute
hospital services, except, of course, pediatrics and obstetrics (and here they
may be encountered as relatives of the primary patients). Although the
procedure or diagnostic problem for which they are hospitalized will dictate
many of their service needs, there are some basic measures that can enhance
the quality of the hospital experience, as described in Box 10-2.
BOX 10-2 Measures That Enhance the Quality

of Hospital Care for Older Adults
Perform a comprehensive assessment. It is not uncommon for the
patient’s diagnostic problem to be the primary and sometimes only
concern during the hospitalization. However, the patient being treated for
a myocardial infarction or hernia may also suffer from depression,
caregiver stress, hearing deficit, or other problems that significantly
affect the health status. By capitalizing on the contact with the patient
during the hospitalization and conducting a comprehensive evaluation,
nurses can reveal risks and problems that affect the health status and that
have not been detected before. Broader problems, other than those for
which the patient was admitted to the hospital, should be explored.
Recognize differences. Older patients should not be considered in the
same way as younger patients: different norms may be used to interpret
laboratory tests and clinical findings, the signs and symptoms of disease
can appear atypically, more time is needed for care activities, and drug
dosages must be age adjusted. The priorities of older patients can differ
from those of younger patients. Nurses must be able to differentiate
normal pathology from pathology in older adults and understand the
modifications that must be made in caring for this population.
Reduce risks. The hospital experience can be traumatic for older
patients if special protection is not afforded. The elderly require more
time to recover from stress; therefore, procedures and activities must be
planned to provide rest. Altered function of major systems and decreased
immunity make it easy for infections to develop. Reduced ability of the
heart to manage major shifts in fluid load demands close monitoring of
intravenous infusion rates. Lower normal body temperature, the lack of
shivering, and reduced capacity to adapt to severe changes in
environmental temperature require that older patients receive special
protection against hypothermia. Differences in pharmacodynamics and
pharmacokinetics in older adults alter their response to medications and
heighten the need for close monitoring of drug therapy. The strange
environment, sensory deficits, and effects of illness and medications
cause falls to occur more easily and make injury prevention a priority.
Confusion often emerges as a primary sign of a complication,
challenging staff to detect this disorder promptly and identify its cause.
Nurses should ensure that measures are taken to reduce patients’ risks
and recognize complications promptly when they do occur.
Maintain and promote function. Priorities addressing the primary
reason for admission usually take the forefront during a patient’s
hospitalization. For example, the arrhythmia must be corrected, the
infection controlled, and the fracture realigned. In the midst of diagnostic
procedures and treatment activities, there must be consideration of
factors that will ensure the older patient’s optimal function and
independence.
Increasingly, hospitals are establishing special services for older adults,

such as geriatric assessment centers, telephone hot lines, long-term care
units, and home visits. Local medical societies and state hospital
associations can answer inquiries about specific hospitals.
Two issues that gerontological nurses need to consider regarding the
hospital care of older adults are abbreviated stays and the move toward
same-day outpatient services for procedures that once would have required
hospitalization. Although shortening hospital stays can be effective in
lowering costs and perhaps reducing or eliminating a patient’s hospital-
induced complications, many older patients require a longer recovery time
than younger adults and may not have adequate assistance in the home.
Nurses must assess older patients’ capacity to care for themselves—the
ability to obtain and prepare food and manage their households—before
discharge and arrange assistance as necessary. A telephone call after
discharge to check on the patient’s status is also useful. (Additional
information on hospital care of older adults is provided in Chapter 33.)
Nursing Homes
Nursing homes provide 24-hour supervision and nursing care to persons
who are unable to be cared for in the community. Chapter 34 discusses
these facilities and related nursing responsibilities.
KEY CONCEPT
The Centers for Medicare and Medicaid Services offer a free online
booklet, Your Guide to Choosing a Nursing Home, or Other Long-Term
Services & Supports which can aid individuals in finding and comparing
facilities, understanding nursing payment for this care, and learning
about alternatives to nursing home care. It is available at
https://www.medicare.gov/Pubs/pdf/02174-Nursing-Home-Other-Long-
Term-Services.pdf.

As the emphasis on holistic health and public awareness of and desire for
complementary and alternative therapies grow, older adults may seek new
or nonconventional types of services (Fig. 10-3). Examples of
complementary and alternative services include the following:
FIGURE 10-3 Increasingly, older adults are turning to
yoga, meditation, and other complementary health
practices.
Wellness and renewal centers

Education, counseling, and case management from alternative
practitioners
Acupuncture and acupressure
Tai chi, yoga, and meditation classes
Therapeutic touch and healing touch
Medicinal herbal prescriptions
Herbal and homeopathic remedies
Guided imagery sessions
Sound, light, and aromatherapy
Nurses possess a wide range of knowledge and skills that, when

combined with additional preparation in complementary and alternative
therapies, makes them ideal providers of some of these nonconventional
services. Even if they are not direct providers of alternative therapies,
nurses can advocate for older adults’ rights to make informed choices about
using such therapies; educate them about the benefits, risks, and limitations
of therapies; and help them find reputable providers. Ideally, these therapies
are used in concert with conventional ones in an integrative care model to
enable patients to use the best of both worlds. Nurses should ensure that the
complementary and alternative therapies used have evidence supporting
their claims and do not interfere or interact with other therapies. The
National Center for Complementary and Integrative Health provides
information on various complementary and alternative therapies that can
guide evidence-based strategies for integrating these therapies with
conventional medicine (see listing in the “Resources” section at the end of
this chapter).
POINT TO PONDER
Increasing numbers of nurses are offering complementary therapies in
independent practices. What types of factors must be considered when
establishing a private practice? What do you think prevents more nurses
from becoming self-employed nurse entrepreneurs?
MATCHING SERVICES TO NEEDS

The needs of the aging population are diverse and multitudinous. In
addition, the needs of an individual older adult are dynamic; in other words,
needs fluctuate as capacities and life demands change. These conditions
require gerontological nursing services to be planned with consideration of
several factors:
Services must address physical, emotional, social, and spiritual

factors. Services must be available to meet the unique needs of the
older population in a holistic manner. These services should be
planned to address whatever problems or needs older adults are likely
to develop and should be implemented in a manner relevant to the
unique characteristics of this group. For instance, a local health
department interested in meeting the special needs of older adults
could add screening programs for hearing, vision, hypertension, and
cancer to their existing services. Likewise, a social service agency with
an abundance of programs for younger families may decide that a
widow’s support group and retirement counseling services are relevant
additions. The consideration of physical, emotional, social, and
spiritual factors is essential to providing holistic nursing care.
Services must consider unique and changing needs. Physical,
emotional, social, and spiritual services are based on the individual’s
needs at a given time, recognizing that priorities are not fixed. An
older adult could be seen in an outpatient medical service for
hypertension control and during that visit express concern regarding a
recent rent increase. Unless assistance is obtained to provide additional
income or lower cost housing, the potential effects of this social
problem, such as stress and dietary sacrifices, may exacerbate the
individual’s hypertension. Ignoring this individual’s need for particular
social services, then, can minimize the effectiveness of the health
services provided.
Care and services must be flexible. Opportunities must exist for the
older individual to move along the continuum of care, depending on
his or her capacities and limitations at different times. Perhaps an older
woman lives with her children and attends a senior citizen recreational
program during the day. If this woman fractures her hip, she may move
along the continuum to hospitalization for acute care and then to a
nursing home for convalescence. As her condition improves and she
becomes more independent, she moves along the continuum to home
care and then possibly adult day care until she regains full
independence.
Services must be tailored to needs. Individualization must be practiced
to match the unique needs of the individual with specific services. Just
as it is inappropriate to assume that all persons over 65 years require
nursing home placement, it is equally inappropriate to assume that all
older persons would benefit from counseling, sheltered housing, home-
delivered meals, adult day care, or any other service. Older
individuals’ unique capacities and limitations and, most importantly,
their preferences should be assessed to identify the most appropriate
services for them.
The listing of resources at the end of the chapter can help gerontological
nurses and nursing students locate and perhaps stimulate services for older
adults. Nurses are encouraged to contact their local agencies on aging and
information and referral services for the location of services within specific
communities.
SETTINGS AND ROLES FOR

GERONTOLOGICAL NURSES
Because the continuum of care includes community-based services,
institution-based services, or a combination of both, gerontological nurses
have an exciting opportunity to practice in a variety of settings. Some of
these settings, such as long-term care facilities and home health agencies,
have a long history of nursing participation. Others, such as senior housing
complexes and adult day care centers, offer new opportunities for nurses to
demonstrate creativity and leadership.
Although nurses’ specific roles and responsibilities can differ vastly in
different settings, gerontological nurses in any setting may serve similar
functions (Box 10-3). These functions are varied and multifaceted and
address the following goals:
BOX 10-3 Functions of the Gerontological

Nurse
Guide persons of all ages toward a healthy aging process.
Eliminate ageism.
Respect the rights of older adults and ensure others do the same.
Oversee and promote the quality of service delivery.
Notice and reduce risks to health and well-being.
Teach and support caregivers.
Open channels for continued growth.
Listen and support.
Offer optimism, encouragement, and hope.
Generate, support, use, disseminate, and participate in research.
Implement restorative and rehabilitative measures.
Coordinate and manage care.
Assess, plan, implement, and evaluate care in an individualized, holistic
manner.
Link services with needs.
Nurture future gerontological nurses for advancement of the specialty.
Understand the unique physical, emotional, social, and spiritual aspects
of each older adult.
Recognize and encourage the appropriate management of ethical
concerns.
Support and comfort through the dying process.
Educate to promote self-care and optimal independence.
Educate persons of all ages in practices that promote a positive aging

experience.
Assess and provide interventions related to nursing diagnoses.
Identify and reduce risks.
Promote self-care capacity and independence.
Collaborate with other health care providers in the delivery of services.
Maintain health and integrity of the aging family.
Advocate for and protect the rights of older adults.
Promote the use of ethics and standards in the care of older adults.
Help older persons face the transition to death with peace, comfort,
and dignity.
As the presence of older adults in diverse health care settings continues

to increase, there will be a crucial need in such settings for nurses with
gerontological nursing expertise. These nurses must understand normal
aging, unique presentations and management of geriatric health problems,
pharmacodynamics and pharmacokinetics in later life, psychological
challenges, socioeconomic issues, spirituality, family dynamics, unique
risks to health and well-being, and available resources. By possessing
gerontological nursing knowledge and skills, nurses can promote efficient,
effective, and appropriate health care services to older adults in a variety of
settings.
A Caregiver Educational Program: A Video

Program to Promote Aging Services Technologies
Awareness
Source: Tam, J. W., & Schmitter-Edgecombe, M. (2019). Geriatric Nursing
, 40 (1), 78–83.
There is evidence that aging services technologies can assist caregivers
and reduce their burden. These technologies address topics such as
medication reminders, grab bars, and the use of assistive devices, as well as
ways to reduce caregivers’ burdens. Despite the benefits, these technologies
are underutilized. To reduce caregivers’ burden and promote optimum
management of the health conditions of those they care for, improved ways
to foster the use of aging services technologies could prove beneficial. This
study evaluated the effectiveness of a video-based educational program
aimed to increase caregivers’ knowledge.
Researchers recruited participants through support groups, hospitals,
and other local agencies. Participants viewed videos on the topics of daily
living aids, medication management, memory aids, fall prevention, and
communication. Participants then took questionnaires that measured
knowledge, attitude, stigma, self-efficacy, and caregivers’ intention to
engage in activities pertaining to the aging services technology. The study
showed that younger caregivers were more accurate in identifying
technologies that could be of use and that both younger and older caregivers
benefited from the program by expanding their understanding of
technologies that could ease caregiver burdens.
Nurses can assist caregivers in providing care and reducing their stress
by helping them to use aging services technologies. In addition to making
caregivers aware of these resources, nurses should assess the ability of
caregivers to use and access technologies and should provide support,
guidance, and education as needed.
PRACTICE REALITIES
An 81-year-old Ms. Jacobs has always been an independent woman. Never
married, and with no surviving relatives, she lives alone in a large house
located on several acres in a rural community that she has lived in for
nearly 50 years. She has no interest in relocating as she enjoys her garden
and the ability to have pets.
Although still independent, Ms. Jacobs can’t get around as well as she
once could and in the past year has had a few minor accidents when driving
into town. She is competent and has the right to remain in her home, but
you are concerned for her safety and welfare.
What could you do to help Ms. Jacobs? How could her changing needs
be balanced with her desire for independence?

1. How would you defend the position that nurses are ideal geriatric care
managers?
2. Mrs. Johns is a 79-year-old woman who has been admitted to an acute
medical hospital for a fractured femur. The orthopedic surgeon
anticipates no problem in Mrs. Johns ambulating and eventually
returning to the community, provided she is successful in her
rehabilitation program. You learn that she lives with her son’s family
in a large metropolitan area. She has a dementia that requires close
supervision and reminders to toilet, dress, and eat; however, with these
reminders, she is physically capable of performing activities of daily
living. Based on this information, what are the various types of
services that can help Mrs. Johns and her family throughout the course
of her recovery?
3. What could you do to stimulate the development of services for aging
persons in your community? What resources could you mobilize to
assist you in this effort?
Chapter Summary
The needs of older adults can fall along a continuum based on their health,
conditions that have to be managed, resources available to them, and level
of function and independence. Not only will different older adults require
different types of services along the continuum, but different types of
services may be needed by an individual at various times based on changes
in status.
Supportive and preventive services assist independent people who
reside in the community to maintain their self-care and avoid physical,
emotional, social, and spiritual problems. Partial and intermittent care
services provide help to persons with a partial limitation in their self-care
capacity or who have a therapeutic demand that requires occasional
assistance. Complete and continuous care services offer assistance to
individual who need 24-hour assistance or supervision.
Complementary and alternative services are increasingly being used by
aging individuals. Although these can be a beneficial complement to
conventional therapies, they need to be used carefully.
When assisting older adults in selecting and using therapies, it is
important for nurses to assure patients’ holistic needs are addressed,
flexibility exists in accessing and using services, and services are
individualized to meet specific needs. Regardless of the service setting,
gerontological nurses should adhere to sound nursing standards, advocate
for patients, actively promote maximum independence, and identify and
reduce potential risks.
Online Resources
General
Aging Life Care Association
http://aginglifecare.org
Administration on Aging Eldercare Locator Page
https://eldercare.acl.gov/Public/About/Aging_Network/AoA.aspx
American Association of Retired Persons
http://www.aarp.org
American Geriatrics Society
http://www.americangeriatrics.org
American Health Care Association
http://www.ahca.org
http://www.ahna.org
American Nurses Association Council on Gerontological Nursing
https://www.nursingworld.org/our-certifications/
American Society on Aging
http://www.asaging.org
Children of Aging Parents
http://www.caps4caregivers.org
Department of Housing and Urban Development
https://www.hud.gov/topics/information_for_senior_citizens
Design for Aging, American Institute of Architects
http://www.aia.org/dfa
The Gerontological Society of America
http://www.geron.org
Gray Panthers
http://www.graypanthers.org
Hispanic Federation
http://www.hispanicfederation.org
National Adult Day Services Association
http://www.nadsa.org
National Association of Area Agencies on Aging
http://www.n4a.org
National Caucus and Center on Black Aged, Inc.
http://www.ncba-aged.org
National Center for Complementary and Integrative Health
http://www.nccih.nih.gov
National Continuing Care Residents Association
naccra.com
National Council on Aging
http://www.ncoa.org
National Eldercare Locator
http://www.eldercare.acl.gov
National Gerontological Nursing Association
http://www.ngna.org
National Hospice and Palliative Care Organization
http://www.nhpco.org
National Institute on Aging
http://www.nia.nih.gov
Program of All-Inclusive Care for the Elderly (PACE)
https://www.medicaid.gov/medicaid/ltss/pace/index.html
Nursing Homes
American Association of Directors of Nursing Services Long-Term Care
https://www.aadns-ltc.org
http://www.ahcancal.org
Leading Age
https://www.leadingage.org
National Association of Directors of Nursing Administration in Long-Term
Care
http://www.nadona.org
National Association for Home Care & Hospice
http://www.nahc.org
Consumer Voice
http://www.theconsumervoice.org
Visiting Nurse Associations of America
http://www.vnaa.org
Adult Day Care

National Adult Day Services Association
http://www.nadsa.org
Support Groups
Please refer to resource listings throughout the book under the specific
condition.
References
Centers for Disease Control and Prevention. (2019). National Center for Chronic Disease and Health
Promotion: Promoting health for older adults. Retrieved January 10, 2020 from
https://www.cdc.gov/chronicdisease/resources/publications/factsheets/promoting-health-for-
older-adults.htm
Healthcare Cost and Utilization Project. (2018). Opioid-related inpatient stays and emergency
department visits among patients aged 65 years and older. Retrieved January 11, 2020 from
https://www.hcup-us.ahrq.gov/reports/statbriefs/sb244-Opioid-Inpatient-Stays-ED-Visits-Older-
Adults.jsp?
National Adult Day Services Association. (2019). Overview and facts. Retrieved January 11, 2020
from http://www.nadsa.org/consumers/overview-and-facts/
National Center for Health Statistics. (2019). Vital and Health Statistics: Long-term care providers
and services users in the United States, 2015-2016. Retrieved January 11, 2020 from
https://www.cdc.gov/nchs/data/series/sr_03/sr03_43-508.pdf
UNIT 3
Health Promotion
12 Sleep and Rest
14 Safety
CHAPTER 11
Nutrition and Hydration
Chapter Outline
Nutritional Needs of Older Adults
Hydration Needs of Older Adults
Promotion of Oral Health
Threats to Good Nutrition
Anorexia
Dysphagia
Constipation
Malnutrition
Addressing Nutritional Status and Hydration in Older Adults
LEARNING OBJECTIVES
1. List age-related factors that affect dietary requirements in late life.

2. Identify risks associated with the use of nutritional supplements.
3. List the special nutritional needs of aging women.
4. Describe age-related changes affecting hydration in older adults.
5. Identify causative factors and signs of dehydration.
6. Describe oral health problems that could influence nutritional status
and recommended oral hygiene for older adults.
7. Outline threats to good nutrition in late life and ways to minimize
them.
TERMS TO KNOW
Anorexialoss of appetite
Dysphagiadifficulty swallowing due to difficulty moving food from the
mouth to the esophagus (transfer dysphagia), down the esophagus
(transport dysphagia), or from the esophagus into the stomach (delivery
dysphagia)
Nutrition has a profound impact on health and functional capacity.

Nutritional status influences one’s ability to defend the body against
disease, maintain anatomic and structural normality, think clearly, and
possess the energy and desire to engage in social activity. With age, there
are numerous changes, often subtle and gradual, that can progressively
jeopardize the ability of older persons to maintain good nutritional status.
This contributes to the fact that an estimated 25% of community-based
older adults and a majority of those in nursing homes have a loss of appetite
and poor dietary intake (Batchelor-Murphy, Steinberg, & Young, 2019).
Factors impacting dietary intake demand special nursing attention (Table
11-1).
TABLE 11-1 Aging and Risks to Nutritional Status

NUTRITIONAL NEEDS OF OLDER
ADULTS

Although the body’s needs for basic nutrients are consistent throughout life,
the required amount of specific nutrients may vary. One of the most
significant differences in nutrient requirements among people of different
ages involves caloric intake. Several factors contribute to the older person’s
reduced need for calories:
The older body has less lean body mass and a relative increase in
adipose tissue. Adipose tissue metabolizes more slowly than does lean
tissue and does not burn calories as quickly.
Basal metabolic rate declines 2% for each decade of life after age 25,
which contributes to weight increase when the same caloric intake of
younger years is consumed.
The activity level for most older adults is usually lower than that
during their younger years.
Although each person has a unique caloric need based on individual

body size, metabolism, health status, and activity level, some
generalizations can be made. Caloric needs gradually decrease throughout
adulthood as a result of age-related changes, and a reduction in calories is
recommended beginning in the fourth decade of life. Current research
shows that a low protein intake, along with a high caloric and sugar intake,
increases the risk of cognitive impairment in late life (Karstens et al., 2019;
Richard et al., 2018). Quantity and quality of caloric intake must be
monitored. One useful way to determine resting caloric needs that considers
age and basal metabolic rate, among other factors, is the Harris-Benedict
equation, also called the resting energy expenditure. With this equation, the
resulting number that is obtained represents the number of calories that
need to be consumed daily to maintain current body weight with no
exercise expenditure. (There are online sites that will perform the
calculations for you.)
Weight in kilograms/heightin centimeters:
Weight in pounds/heightin inches:

In addition to monitoring quantity, it is important to monitor the quality
of calories consumed. Because caloric requirements and intake are often
reduced in later life, the ingested calories need to be of higher quality to
ensure an adequate intake of other nutrients (Fig. 11-1). Limiting dietary fat
intake to less than 30% of total calories consumed is a good practice for
older adults. Table 11-2 lists the recommended daily allowances (RDAs) for
older adults.
FIGURE 11-1 Although they usually need to ingest fewer

calories than do younger persons, older adults’ diets must
include a high quality of nutrients.
TABLE 11-2 Recommended Dietary Allowances (RDA) for

People Over 50 Years of Age
aVitamin D RDA for men and women 71 years and over is 800 IU.
bCalcium RDA for men 71 years and over is 1,200 mg.
Fiber is particularly important in the older adult’s diet. Soluble fibers,

found in foods such as oats and pectin, help to lower serum cholesterol;
improve glucose tolerance in diabetics; and prevent obesity, cardiovascular
disease, and colorectal cancer (Gaesser, Rodriguez, Patrie, Whisner, &
Angadi, 2019; O’Keefe, 2019). Insoluble fibers promote good bowel
activity and can be found in grains and many vegetables and fruits.
Carbohydrates provide important sources of energy and fiber. However,
because of a decreased ability to maintain a regular blood glucose level,
older adults need a reduced carbohydrate intake. A high-carbohydrate diet
can stimulate an abnormally high release of insulin in older adults. This can
cause hypoglycemia, which can first present in older adults as a confused
state.
At least 1 g protein per kilogram of body weight is necessary to renew
body protein and protoplasm and to maintain enzyme systems. If 20% to
30% of daily caloric intake is derived from protein, protein requirements
should be met. Several protein supplements are available commercially and
may be useful additives to the older person’s diet.
Although the ability to absorb calcium decreases with age, calcium is
still required in the diet to maintain a healthy musculoskeletal system, as
well as to promote the proper functioning of the body’s blood clotting
mechanisms. Older adults may benefit from calcium supplements, but they
should discuss their use with their physicians to ensure that other medical
problems do not contraindicate them. In addition, caution is needed to avoid
excess calcium consumption (see discussion under Nutritional
Supplements). A good intake of vitamin D and magnesium facilitates
calcium absorption.
It is recommended that older adults eat at least five servings of fruits
and vegetables daily. Unfortunately, a majority of older adults fail to
consume the recommended amounts (Lee-Kwan, Moore, Blanck, Harris, &
Galuska, 2018). The nurse can discuss with older adults the importance of
consuming adequate fruits and vegetables and make suggestions on the
variety of ways that they can be consumed (e.g., in smoothies or mixed in
yogurt or gelatin).
Researchers at the U.S. Department of Agriculture (USDA) Human
Nutrition Research Center on Aging (HNRCA) at Tufts University have
offered a modification to the USDA’s MyPlate to more accurately reflect
the dietary needs of persons over age 70 years (Fig. 11-2; Tufts University,
2019). This replaces the Modified MyPyramid for Older Adults and
provides examples of foods that are consistent with the federal
government’s 2015–2020 Dietary Guidelines for Americans. These
guidelines limit foods high in trans and saturated fats, salt, and added
sugars. They emphasize whole grains and foods with high levels of
vitamins and minerals per serving.
FIGURE 11-2 Modified MyPlate for older adults.

Available at https://hnrca.tufts.edu/myplate/ (“MyPlate for
Older Adults” Copyright 2016 Tufts University, all rights
reserved; reprinted with permission. “MyPlate for Older
Adults” graphic and accompanying Web site were
developed with support from the AARP Foundation.
“Tufts University” and “AARP Foundation” are registered
trademarks and may not be reproduced apart from their
inclusion in the “MyPlate for Older Adults” graphic
without express permission from their respective owners.)
POINT TO PONDER
How do you see your diet affecting your body, mind, and spirit and vice
versa? Are there patterns that need to be changed, and, if so, how?
CONSIDER THIS CASE
Mrs. Valenti is an 80-year-old woman who

lives in the community with her husband. She is an active woman who
does her own housekeeping and cooking and is active in her church.
Throughout her adult life, Mrs. Valenti has been about 10 to 15 lb
above her ideal weight. Over the past few years, her blood pressure and
cholesterol levels have been elevated. In reviewing her diet, the nurse
discovers that although she does eat fruits and vegetables daily, Mrs.
Valenti consumes a diet that is high in fat and calories. When the nurse
begins discussing diet modifications with her, Mrs. Valenti laughs and
responds, “My husband and I have always eaten Italian food, and we don’t
want to change. What is the point of living longer if you’re not enjoying
life?”
THINK CRITICALLY
1. How can the nurse influence a change in Mrs. Valenti’s diet while
respecting her preferences?
2. What plan of care could be developed to address Mrs. Valenti’s
dietary issues?
Today, more than half of all adults take nutritional supplements on a daily
basis. Vitamin and mineral requirements for older adults are undetermined,
and presently, the RDAs for the general adult population need to be applied
to the older age group. Although not a panacea, nutritional supplements can
compensate for inadequate intake of nutrients and deficiencies resulting
from diseases and medication effects. Niacin, riboflavin, thiamine, and
vitamins B6, C, and D are the most common nutrients found to be deficient
in older adults. However, caution is needed because vitamins, minerals, and
herbs, particularly in high doses, can produce adverse effects (Tables 11-3
and 11-4) and interact with many medications (Table 11-5).
TABLE 11-3 Risks Associated With Excess Intake of Selected

Vitamins and Minerals
TABLE 11-4 Adverse Effects of Extended or Excessive Use of
Selected Herbs
TABLE 11-5 Herb–Drug Interactions
For example, excess calcium consumption (i.e., in excess of 2,000

mg/d) can lead to problems such as kidney stones and an increased risk of
cancer (Collins, 2019). If calcium supplements are used, no more than 500
mg should be taken at any one time because larger amounts are not
absorbed as well. With the increasing number of calcium-fortified products
available, older adults should check labels and total the amount of calcium
they consume from various sources. Consideration must also be given to the
food with which calcium supplements are taken, because wheat bran,
soybeans, and other legumes can interfere with the calcium absorption.
The nursing assessment should include a review of the type and amount
of nutritional supplements used. Nurses can encourage older adults to avoid
excess intake of supplements and to review the use of nutritional
supplements with their health care providers.
KEY CONCEPT
Vitamin, mineral, and herbal supplements can be beneficial, but caution
is needed to avoid adverse consequences from their misuse.

Heart disease, cancer, and osteoporosis are among the nutrition-related
conditions to which older women are susceptible. Attention to dietary
requirements and reduction of diet-related risks can reduce some of these
problems.
From 64 to 74 years of age, the rate of heart disease among women
equals that of men. The reduction of fat intake to 30% kcal or less (70 g in a
1,800-cal diet) can be beneficial in reducing the risk of heart disease in
older women. Research is attempting to disclose the role of low-fat intake
in reduced risk of breast cancer, which could support another benefit to
limiting fat intake. Alcohol consumption also has a role in breast cancer; the
daily intake of 40 g or more of alcohol has been linked to an increased risk
of breast cancer (40 g of alcohol equals 30 oz of beer or 3 oz of 100-proof
whiskey). Thus, reducing alcohol intake is advisable.
Nearly all women are affected by some degree of osteoporosis by the
time they reach their seventh decade of life. The risk of bone loss is
increased by estrogen reduction, obesity, inactivity, smoking, and the
excessive consumption of caffeine and alcohol. The risk of fracture from
brittle bones and the complications that follow warrant consideration to
prevent bone loss by controlling risks. Postmenopausal women should have
a daily calcium intake of at least 1,000 mg. Calcium from carbonate and
citrate is the most common form of calcium supplement. Calcium
carbonate, the most cost-effective form, should be taken with a meal at
doses of not more than 500 mg at one time to ensure optimal absorption
(Harvard Medical School, 2019).
HYDRATION NEEDS OF OLDER

ADULTS
With age, intracellular fluid is lost, resulting in decreased total body fluids.
Whereas water constitutes approximately 60% of body weight in younger
adults, it constitutes 50% or less of body weight in older adults. This
reduces the margin of safety for any fluid loss; a reduced fluid intake or
increased loss that would be only a minor problem in a younger person
could be life threatening to an older person. The National Academy of
Sciences recommends fluid intake for men 16 glasses per day and for
women 11 glasses per day. Some health conditions may require less fluid
intake, whereas situations like a hot climate or being on a diuretic could
increase fluid needs. Nurses should evaluate older adults for factors that can
cause them to consume less fluid, such as:
Age-related reductions in thirst sensations

Fear of incontinence (physical condition and lack of toileting
opportunities)
Lack of accessible fluids
Inability to obtain or drink fluids independently
Lack of motivation
Altered mood or cognition
Nausea, vomiting, and gastrointestinal distress
When such factors are present or there is any suspicion regarding the
adequacy of fluid intake, fluid intake and output should be recorded and
monitored (see Nursing Problem Highlight 11-1).

DEHYDRATION
Overview
Dehydration is a condition in which intracellular, extracellular, or vascular
fluid is less than that required by the body. This condition can be
demonstrated by increased output, reduced intake, concentrated urine,
weight loss, hypotension, increased pulse, poorer skin turgor, dry skin and
mucous membranes, increased body temperature, weakness, confusion,
and elevated serum creatinine, blood urea nitrogen, and hematocrit.
Vomiting, diarrhea, polyuria, excessive drainage, profuse perspiration,
increased metabolic rate, insufficient intake due to physical or mental
limitation, inaccessible fluids, and medications (e.g., diuretics, laxatives,
sedatives).
Goal
The patient possesses an intake and output balance within 200 mL and has
cause of problem identified and corrected.
Interventions
Perform a comprehensive assessment to identify underlying cause of
fluid volume deficit; obtain treatment for underlying cause as
appropriate.
Maintain a strict record of intake and output.
Closely monitor vital signs, urine specific gravity, skin turgor, and
mental status.
Monitor patient’s weight daily until problem is corrected.
Encourage fluids, at least 15 cups/day for men and 11 cups/day for
women during a 24-hour period unless contraindicated; offer foods
that are high in fluid content (e.g., gelatin, sherbets, soup); keep
fluids easily accessible.
Consult with physician regarding need for intravenous fluid
replacement; if prescribed, monitor carefully because of high risk of
overhydration in elderly persons.
Assist with or provide good oral hygiene.
Identify persons at high risk for dehydration and closely monitor their
intake and output.
Fluid restriction not only predisposes older adults to infection,

constipation, and decreased bladder distensibility but also can lead to
serious fluid and electrolyte imbalances. Dehydration, a life-threatening
condition to older persons because of their already reduced amount of body
fluid, is demonstrated by dry, inelastic skin; dry, brown tongue; sunken
cheeks; concentrated urine; blood urea value elevated above 60 mg/dL; and,
in some cases, confusion.
At the other extreme, older adults are also more sensitive to
overhydration caused by decreased cardiovascular and renal function.
Overhydration is a consideration if intravenous fluids are needed
therapeutically.
KEY CONCEPT
The age-related decline in body fluids reduces the margin of safety when
insufficient fluid is consumed or extra fluid is lost.
PROMOTION OF ORAL HEALTH

Pain-free, intact gums and teeth will promote the ingestion of a wider
variety of food. The ability to meet nutritional requirements in late life is
influenced by basic dental care throughout one’s lifetime. Poor dental care,
environmental influences, inappropriate nutrition, and changes in gingival
tissue commonly contribute to severe tooth loss in older persons. After the
third decade of life, periodontal disease becomes the first cause of tooth
loss. Growing numbers of aging adults are preserving their teeth as they
grow older; however, without attention to the prevention of periodontal
disease, they, too, could face their senior years without the benefit of having
most of their natural teeth. In addition to teaching methods to prevent
periodontal disease, nurses must ensure that older adults and their
caregivers understand the signs of this condition so that they can seek help
in a timely manner. Signs of periodontal disease include the following:
Bleeding gums, particularly when teeth are brushed

Red, swollen, painful gums
Pus at gum line when pressure is exerted
Chronic bad breath
Loosening of teeth from gum line
The use of a toothbrush is more effective than swabs or other soft

devices in improving gingival tissues and removing soft debris from the
teeth. Lemon–glycerin swabs, which contain citric acid, dry the oral mucosa
and contribute to tooth enamel erosion. Mouthwashes with high alcohol
content can be too harsh for older mouths; diluting a commercial
mouthwash with water (half and half) is recommended. Care should be
taken not to traumatize the tissues when performing oral hygiene because
they are more sensitive, fragile, and prone to irritation in older adults. Loose
teeth should be extracted to prevent them from being aspirated and causing
a lung abscess.

Poor oral health can be a cause of malnutrition. Pain-free, intact gums and
teeth will promote the ingestion of a wider variety of foods and influence
nutritional status.
Obviously, a lifetime of poor dental care cannot be reversed. Geriatric

dental problems need to be prevented early in a person’s life. Although the
specialty of geriatric dentistry has grown, many persons do not have access
to this service or the financial means to avail themselves of this care.
Through education, nurses can make the public aware of the importance of
good, regular dental care and oral hygiene at all ages and inform patients
that aging alone does not necessitate the loss of teeth.
COMMUNICATION TIP
When it is identified that an older person has not seen a dentist within
the past year, the nurse should explore the reason for this and tailor a
response based on the reason. For example, if the older adult admits to
financial challenges in affording dental care, he can be assisted in
locating free or low-cost dental services. On the other hand, if the
individual states he didn’t think he still needed to visit a dentist due to
his age or the wearing of dentures, education about the need for dental
care throughout the life span may be warranted.
Many older adults believe that having dentures eliminates the need for
dental care. Nurses must correct this misconception and encourage
continued dental care for the individual with dentures. Lesions, infections,
and other diseases can be detected by the dentist and corrected to prevent
serious complications from developing. Changes in tissue structure may
affect the fit of the dental appliances, which then require readjustment.
Poorly fitting dentures need not always be replaced; sometimes, they can be
lined to ensure a proper fit. Nurses can explain this to older adults, who
may resist correction because of concern for the expense involved. Most
importantly, dental appliances should be used and not kept in a pocket or
dresser drawer! Wearing dental appliances allows proper chewing,
encouraging older people to introduce a wider variety of foods into their
diets.
KEY CONCEPT
Dental problems can affect virtually every system of the body; therefore,
they must be identified and corrected promptly.
THREATS TO GOOD NUTRITION

Indigestion and food intolerance are common among older people because
of decreased stomach motility, less gastric secretion, and a slower gastric
emptying time. Older persons frequently attempt to manage these problems
by using antacids or limiting food intake, but both strategies potentially
predispose them to other risks. Other means for managing these problems
should be explored. For example, the nurse can suggest eating several small
meals rather than three large ones. This not only provides a smaller amount
of food to be digested at one time but also helps to maintain a more stable
blood glucose level throughout the day. Avoiding or limiting fried foods
may be helpful, since it is easier to digest broiled, boiled, or baked food.
When food intolerance exists, the person can eliminate specific foods from
the diet. Often, older adults need help identifying problem foods,
particularly if they have included those foods in their diets throughout their
entire lives. Sitting in a high Fowler’s position while eating and for 30
minutes after meals is helpful as it increases the size of the abdominal and
thoracic cavities, provides more room for the stomach, and facilitates
swallowing and digestion. Finally, ensuring adequate fluid intake and
activity promotes the motility of food through the digestive tract.
KEY CONCEPT
Self-imposed dietary restrictions and misuse of antacids to manage
indigestion can create a new set of problems for older adults.
Anorexia
Anorexia can be related to a variety of conditions, including medication
side effects, inactivity, physical illness, or age-related changes, such as
decreased taste and smell sensations, reduced production of the hormone
leptin, and gastric changes that cause satiation with smaller volumes of food
intake. In the older adults particularly, losses and stresses (e.g., death of
loved ones, loneliness, financial worries, and living with effects of chronic
conditions) could cause anxiety and depression that could affect appetite.
The initial step in managing this problem is to identify its cause.
Depending on the cause, treatment could consist of a high-calorie diet,
referral to social programs, tube feeding, hyperalimentation, psychiatric
therapy, or medications. Some stimulation to the appetite can be achieved
through the use of lemon, pomegranate, and cranberry juice and certain
herbs, such as ginger root, ginseng, and peppermint. Intake, output, and
weight should be monitored; weight loss greater than 5% within a 1-month
period and 10% within a 6-month period is considered significant and
requires evaluation.
Dysphagia
The incidence of dysphagia increases with age and can take several forms,
such as difficulty moving food from the mouth to the esophagus (transfer
dysphagia), down the esophagus (transport dysphagia), or from the
esophagus into the stomach (delivery dysphagia). Neurologic conditions,
such as a stroke, can cause dysphagia, although most cases result from
gastroesophageal reflux disease.
A careful assessment that identifies specific swallowing problems is
useful in planning the best interventions for the person experiencing
dysphagia. Factors to consider include onset, types of foods that present the
most problem (solids or liquids), consistent or periodic occurrence, and
other symptoms and related complications (e.g., aspiration or weight loss).
A referral to a speech pathologist is beneficial in evaluating the problem
and developing an individualized care plan.
Although specific interventions will be used to address an individual’s
needs, some general measures prove useful for all persons with dysphagia,
such as having the person sit upright whenever food or fluid is being
consumed; allowing sufficient time for eating; ensuring there is no residual
food in the mouth before feeding additional food; placing small portions in
the mouth; discouraging the person from talking while eating; keeping a
suction machine readily available; and monitoring intake, output, and
weight. Often, thickened liquids or mechanically altered foods may prove
beneficial. Tilting the head to a side and placing food on a particular part of
the tongue may be recommended, as may correction of an underlying
problem, such as obesity or removal of a structural obstruction.
Constipation
Constipation is a common problem among older persons because of slower
peristalsis, inactivity, side effects of drugs, and a tendency toward less fiber
and fluid in the diet. If food intake is reduced to relieve discomfort,
nutritional status can be threatened. Laxatives, another relief measure, can
result in diarrhea, leading to dehydration; if oil-based laxatives are used,
fat-soluble vitamins (e.g., A, D, K, and E) can be drained from the body,
leading to vitamin deficiencies.
Nurses must recognize constipation as a frequent problem for older
adults and encourage preventive measures. Plenty of fluids, fruits,
vegetables, and activity is advisable, as is regular and adequate time
allowance for a bowel movement. Activity promotes peristalsis and should
be encouraged. Fiber is important but must be used with care to avoid
cramping and bloating. The lower gastric acidity contributes to bezoar
development, which is demonstrated by nausea, vomiting, fullness,
abdominal pain, and diarrhea. Senna is an effective natural laxative that can
be consumed in tablet or tea form. Often, individuals are aware that certain
foods (e.g., bananas, prunes, carrots, or oatmeal) facilitate bowel
elimination; these should be incorporated into the diet on a regular basis.
Laxatives should be considered only after other measures have proved
unsuccessful and, when necessary, should be used with great care.
Malnutrition
Because malnutrition is a potential and serious threat to older people, it
should be closely monitored. The factors contributing to this problem
include decreased taste and smell sensations, reduced mastication
capability, slower peristalsis, decreased hunger contractions, reduced gastric
acid secretion, less absorption of nutrients because of reduced intestinal
blood flow, and a decrease in cells of the intestinal absorbing surface. The
effects of medications can contribute to malnutrition (Box 11-1),
reinforcing the significance of using nonpharmacologic means to address
health conditions when possible. Socioeconomic factors contributing to
malnutrition also must be considered, along with lifelong eating patterns
(e.g., history of skipping breakfast or high consumption of “junk foods”).
BOX 11-1 Nutritional Risks Associated With

Select Medications
The appearance of older people can be misleading and delay the
detection of a malnourished state. Some of the clinical signs of malnutrition
include the following:
Weight loss greater than 5% in the past month or 10% in the past 6
months
Weight 10% below or 20% above ideal range
Serum albumin level lower than 3.5 g/100 mL
Hemoglobin level below 12 g/dL
Hematocrit value below 35%
Other problems can indicate malnutrition, such as delirium, depression,

visual disturbances, dermatitis, hair loss, pallor, delayed wound healing,
lethargy, and fatigue. It is crucial that nurses use keen assessment skills to
recognize early malnourishment in older adults and encourage good
nutritional practices to prevent its occurrence.
ADDRESSING NUTRITIONAL STATUS

AND HYDRATION IN OLDER ADULTS
A wide range of physical, mental, and socioeconomic factors affect
nutritional status in later life. Because these factors can change, regular
nutritional assessment is necessary. Effective nutritional assessment
involves collaboration among a physician, nurse, nutritionist, and social
worker. Assessment Guide 11-1 describes the basic components of the
nutritional assessment.
ASSESSMENT GUIDE 11-1

NUTRITIONAL STATUS
HISTORY
Review health history and medical record for evidence of diagnoses
or conditions that can alter the purchase, preparation, ingestion,
digestion, absorption, or excretion of foods.
Review medications for those that can affect appetite and nutritional
state.
Review the type and amount of any nutritional supplements used.
Ask the patient to describe his or her diet, meal pattern, food
preferences, and restrictions.
Ask the patient if there has been any change in appetite, digestion,
food consumption, or ability to chew or swallow.
Request that the patient keep a diary of all food intake for a week.
PHYSICAL EXAMINATION
Inspect hair. Hair loss or brittleness can be associated with
malnutrition.
Inspect skin. Note persistent “goose bumps” (vitamin B6 deficiency),
pallor (anemia), purpura (vitamin C deficiency), brownish
pigmentation (niacin deficiency), red scaly areas in folds around the
eyes and between the nose and corner of the mouth (riboflavin
deficiency), dermatitis (zinc deficiency), and fungal infections
(hyperglycemia).
Test skin turgor. Skin turgor, although poor in many older adults,
tends to be best in the areas over the forehead and sternum; therefore,
these are preferred areas to test.
Note muscle tone, strength, and movement. Muscle weakness can be
associated with vitamin and mineral deficiencies.
Inspect eyes. Ask about changes in vision and night vision problems
(vitamin A deficiency). Note the patient’s percentile rank.
Inspect oral cavity. Note dryness (dehydration), lesions, condition of
the tongue, breath odor, and condition of teeth or dentures.
Ask about signs and symptoms: sore tongue, indigestion, diarrhea,
constipation, food distaste, weakness, muscle cramps, burning
sensations, dizziness, drowsiness, bone pain, sore joints, recurrent
boils, dyspnea, dysphagia, anorexia, and appetite changes.
Observe person drinking or eating for difficulties.
Biochemical Evaluation
Obtain blood sample for screening of total iron binding capacity,
transferrin saturation, protein, albumin, hemoglobin, hematocrit,
electrolytes, vitamins, and prothrombin time.
Obtain urine sample for screening of specific gravity.
Anthropometric Measurement
Measure and ask about changes in height and weight. Use age-
adjusted weight chart for evaluating weight. Note weight losses of
5% within the past 1 month and 10% with the past 6 months.
Determine triceps skinfold measurement (TSM). To do so, grasp a
fold of skin and subcutaneous fat halfway between the shoulder and
elbow and measure with a caliper. Note the patient’s percentile rank.
Measure the midarm circumference (MC) with a tape measure (using
centimeters) and use this to calculate midarm muscle circumference
(MMC) with the formula:
he standard MMC is 25.3 cm for men and 23.2 cm for women. MMC
T
below 90% of the standard is considered undernutrition; below 60% is
considered protein–calorie malnutrition.
PSYCHOLOGICAL EXAMINATION
Test cognitive function.
Note alterations in mood, behavior, cognition, and level of
consciousness. Be alert to signs of depression (can be associated with
deficiencies of vitamin B6, magnesium, or niacin).
Ask about changes in mood or cognition.
Specific interventions discussed in this chapter can help address threats

to good nutrition and hydration. In addition, it is important to consider that,
often, a minor service link can enhance an older adult’s nutritional status. In
addressing the nutritional needs of older adults, the nurse must consider a
wide range of services, including the Supplemental Nutrition Assistance
Program, formerly known as food stamps, Meals on Wheels, shopping and
meal preparation assistance through volunteer organizations, home health
aides for feeding assistance, congregate eating programs, and nutritional
and psychological counseling.
In addition to the physiological considerations, the social and cultural
aspects of food are important to consider. To many people, the preparation,
serving, and consumption of food signify a caring act. Social connection
with others and celebrations typically involve food. Appreciation is often
expressed through the gift of an edible treat. Encouraging friends and
family to bring special treats to older persons who are in the hospital or
nursing home and assisting them in engaging in celebrations are beneficial
acts. For example, in a nursing home setting, nursing staff can assist a
resident’s family in finding a private area in the facility in which they can
host a family luncheon to celebrate a special event.
The nurse must also consider cultural variables affecting nutrition.
Ethnic and religious factors can influence food selection and preparation
and eating patterns and practices. In some cultures, specific foods are seen
as having healing benefit. For example, some Asian Americans believe that
health is a balance of yin and yang and may select certain hot or cold foods
to restore balance. An understanding of unique cultural factors affecting
dietary practices is essential to individualized care.
COMMUNICATION TIP
Although there are some common dietary practices and food
preferences among specific ethnic and religious groups, not all
members of such a group follow those practices. Nurses should ask
patients about their specific food preferences.

Dietary Education With Customized Dishware and Food Supplements
Can Reduce Frailty and Improve Mental Well-Being in Elderly People:
A Single-Blind Randomized Controlled Study
Source: Wu, S. Y., Hsu, L. L., Hsu, C. C., Hsieh, T. J., Su, S. C., et al.
(2018). Asia Pacific Journal Clinical Nutrition , 27(5), 1018–1030 .
Frailty is a common geriatric syndrome that can be prevented and
reversed. This 3-month study compared the effects of protein supplement
and/or micronutrients and a personalized diet on prefrail and frail older
adults. Dietary intake, protein biomarkers, geriatric depression score, and
frailty score were analyzed.
The study showed that interventions of two sessions of consultation,
food supplements, and customized easy-to-comprehend dishware that
designated spaces on the plate that were to be filled with specific food types
improved nutritional outcomes.
This study demonstrates the significance of providing practical
educational tools that address individual capabilities and needs—in this
case, customized dishware—to reinforce proper nutritional intake. Although
educational sessions and printed literature are beneficial in presenting good
nutritional principles and dietary plans to older adults, memory deficits and
the stress of having to absorb various pieces of information (e.g.,
medication administration, treatments, appointments) can cause information
provided through nutritional instruction to be forgotten. Customized
dishware demonstrating the types and amounts of specific foods serves as a
regular reminder and can provide immediate feedback to older individuals
that enables them to evaluate the quantity and quality of their nutritional
intake. As part of their assessment, nurses should explore the potential of
individuals to retain verbal instruction and utilize printed instructions; if
deficits are present, alternative means to promote retention and
reinforcement of information should be considered. As demonstrated in this
study, something as basic as dishware that shows the various types and
amounts of nutrients that should be consumed has the potential to improve
health status and function.
PRACTICE REALITIES
Nurse Timms recently has begun working in a nursing home. On the unit in
which he is assigned, he notices that mouth care is not given. Although
some of the residents have teeth that are in poor condition and dentures that
fit poorly, there is no plan for dental care.
During a staff meeting, Mr. Timms asked about plans for dental care for
the residents. The staff responded, “These people don’t have the money to
visit a dentist, plus, the nearest dentist is nearly an hour away.” The
physician says that if a resident has a dental complaint, a referral to a dentist
will be written, but, otherwise, it is a waste of time and money.
Mr. Timms is not content accepting this but as a new employee doesn’t
want to cause conflict with the team.
What actions could Mr. Timms take?

1. List the various physical, mental, and socioeconomic requisites for
good nutritional intake.
2. What topics could be included in an oral health education program for
older adults?
3. How have the media and advertisements influenced the use of dietary
supplements? What can nurses do to assist older adults in separating
fact from myth regarding the claims made by manufacturers and
distributors of dietary supplements?
4. Describe factors that can negatively influence dietary intake for older
adults in a nursing home, a hospital, and at home.
5. Describe the components of a comprehensive nutritional assessment.
NEXT GENERATION NCLEX-STYLE

CASE STUDY AND QUESTIONS
Below is a case study for this chapter in the Next Generation NCLEX style.
See online Appendix A for the Next Generation NCLEX questions related
to this case study, and see online Appendix B for the answers to those
questions.
A 68-year-old female client presents to the weight management clinic for

her obesity.
Nurse’s Notes
1000: The client indicates that she has gained 50 lb since she retired last
year from her job. She further states that she cannot understand why she
has gained this weight since she only eats one meal a day. She says, “I
have not been exercising like I should since my gym membership was
discontinued because I was not able to pay for it.”
The client lives alone, she seldom leaves her home to go out, and she
eats only frozen meals (steak and pasta) once a day. The client denies
having any medical diagnosis but has a family history of high blood
pressure, diabetes, and obesity. She indicates that she takes an over-the-
counter multivitamin and a weight management herbal supplement that
her sister gave her. She has lost her appetite since taking the herbal
supplement but has not lost weight.
The client smokes half a pack of cigarettes a day and has smoked for
20 years; she drinks three glasses of red wine daily and five cups of
coffee daily because she hates drinking water. Her last dental visit was 2
years ago, and she indicates that she has no money to visit the dentist.
Vital signs: temperature 98.6 oral, pulse 110, respiration 20, and BP
140/80. Weight is 250 lb and height is 5 ft 8 in., with a BMI of 35.9%.
The last bowel movement was 3 days ago. The nurse draws the client’s
blood and sends it out to the lab for CBC (complete metabolic profile),
hemoglobin AIC, fasting cholesterol level, and liver function test. The
bedside glucose test result was 74 fasting. The client declines order for a
nicotine patch to stop smoking and states that she will work on
decreasing her coffee and wine consumption.
Chapter Summary
A healthy nutritional status has a significant impact on mental and physical
health. In advanced age, nutritional needs are altered by factors such as
reduced basal metabolic rate, decreased activity, and a reduction in lean
body mass with an increase in adipose tissue. In general, reduced calories
and a higher quality of nutritional intake are recommended.
Growing numbers of aging individuals are consuming vitamin, mineral,
and herbal supplements. When reviewing nutritional intake, it is also
important to explore the use of supplements to determine they are being
properly used, at a safe dosage level, and not interacting with medications
or other supplements.
A variety of factors contribute to the risk of inadequate fluid intake in
older adults. Nurses should carefully assess fluid intake and encourage an
adequate fluid intake.
Periodontal disease is the major cause of tooth loss in older adults and
can affect food intake. Older persons need to be advised of the importance
of toothbrushing and regular visits to the dentist to preserve their teeth.
Nurses should make sure older patients in all care settings receive adequate
oral hygiene.
Anorexia, dysphagia, constipation, and malnutrition are among the
common nutritional problems presented by older adults. Because a variety
of factors can contribute to each, the nurse should thoroughly explore these
factors during the assessment so that the best plan to address the problem
can be developed.
Online Resources
American Dental Association
http://www.ada.org
Academy of Nutrition and Dietetics
http://www.eatright.org
Food and Nutrition Information Center
www.nal.usda.gov/fnic
Mini Nutritional Assessment
http://mna-elderly.com
National Institute of Dental and Craniofacial Research
www.nidcr.nih.gov
Nutrition.gov: Older Individuals
https://www.nutrition.gov/topics/audience/older-individuals
Overeaters Anonymous
http://www.overeaters.org
U.S. Department of Agriculture Library: Aging
http://nal.usda.gov/fnic/older-individuals
References
Batchelor-Murphy, M. K., Steinberg, F. M., & Young, H. M. (2019). Dietary and feeding
modifications for older adults. American Journal of Nursing , 119 (12):49.
Collins, F. (2019). Study finds no benefit for dietary supplements. NIH Director’s blog, April 16,
2019. Retrieved January 29, 2020 from https:// https://directorsblog.nih.gov/2019/04/16/study-
finds-no-benefit-for-dietary-supplements/
Gaesser, G. A., Rodriguez, J., Patrie, J. T., Whisner, C. M., & Angadi, S. S. (2019). Effects of
glycemic index and cereal fiber on postprandial endothelial function, glycemia, and insulinemia
in healthy adults. Nutrients , 11 (10). Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6835298/
Harvard Medical School. (2019). How much calcium do you really need? Harvard women’s health
watch, September 11, 2019. Retrieved January 29, 2020 from
https://www.health.harvard.edu/staying-healthy/how-much-calcium-do-you-really-need
Karstens, A. J., Tussing-Humphreys, L., Zhan, L., Rajendran, N., Cohen, J., et al. (2019).
Associations of the Mediterranean diet with cognitive and neuroimaging phenotypes of
dementia in healthy older adults. American Journal of Clinical Nutrition , 109 (2), 361–368.
Lee-Kwan, S. H., Moore, L. V., Blanck, H. M., Harris, D. M., & Galuska, D. (2018). Disparities in
state-specific adult fruit and vegetable consumption—United States. Morbidity and Mortality
Weekly Report , 66 , 1241–1247. Retrieved January 29, 2020 from
http://dx.doi.org/10.15585/mmwr.mm6645a1
O’Keefe, S. J. (2019). The association between dietary fiber deficiency and high-income lifestyle-
associated diseases: Burkitt’s hypothesis revisited. The Lancet Gastroenterology & Hepatology ,
4 (12), 984–996.
Richard, E. L., Laughlin, G. A., Kritz-Silverstein, D., Reas, E. T., Barrett-Connor, E., & McEvoy, L.
K. (2018). Dietary patterns and cognitive function among older community-dwelling adults.
Nutrients , 10 (8). Retrieved January 28, 2020 from
Tufts University. (2019). MyPlate for older adults. Retrieved January 29, 2020 from
https://hnrca.tufts.edu/myplate/
readings and other resources associated with this chapter.
CHAPTER 12
Sleep and Rest
Chapter Outline
Age-Related Changes in Sleep
Sleep Stages
Sleep Disturbances
Insomnia
Nocturnal Myoclonus and Restless Legs Syndrome
Sleep Apnea
Promoting Rest and Sleep in Older Adults
Pain Control
LEARNING OBJECTIVES
1. Explain differences between younger and older adults in sleep stages

and cycles.
2. Describe factors that may disturb sleep in older adults.
3. Describe pharmacologic and nonpharmacologic means to promote
sleep.
4. Discuss the importance of pain control for promoting rest and sleep.
TERMS TO KNOW
Insomniainability to fall sleep, difficulty staying asleep, or premature
waking
Nocturnal myoclonuscondition characterized by at least five leg jerks or
movements per hour during sleep
Phase advancefalling asleep earlier in the evening and awakening earlier
in the morning
Restless legs syndromeneurological disorder characterized by an
uncontrollable urge to move the legs when one lies down
Sleep apneadisorder in which at least five episodes of cessation of
breathing, lasting at least 10 seconds, occur per hour of sleep,
accompanied by daytime sleepiness
Sleep latencydelay in the onset of sleep
All human beings must retreat from activity and stimulation to renew their
reserves. Several periods of relaxation throughout the day and a block of
sleep help promote a healthy pattern of rest. The fact that a person spends
nearly one third of his or her lifetime sleeping and resting underscores the
significance of these activities. Sleep is often a mirror into our state of
health and well-being in that we may be restless and unable to obtain
sufficient sleep in the presence of pain, stress, or impaired bodily functions.
It also is a factor that affects health and well-being, as inadequate quality or
quantity of sleep is associated with risks to physical and mental health.
POINT TO PONDER
What are your unique sleep and rest requirements, and how well do you
meet them? What do you notice about your physical and emotional states
when you have had inadequate sleep and rest?
Changes that occur with aging and conditions experienced in later years
can interfere with the ability to achieve adequate sleep and rest (see Table
12-1). Astute assessment is necessary to ensure that older adults fulfill sleep
and rest requirements and to identify obstacles for which intervention is
warranted.
TABLE 12-1 Aging and Risks to the Ability to Achieve Rest
AGE-RELATED CHANGES IN SLEEP

Insomnia , daytime sleepiness, and napping are all highly prevalent among
the older adults. In most cases, these experiences result from age-related
changes in circadian sleep–wake cycles, sleep architecture (stages), sleep
efficiency, and sleep quality (Li, Vitiello, & Gooneratne, 2018).

Older adults are more likely to fall asleep earlier in the evening and awaken
earlier in the morning, a behavior referred to as phase advance . The
quantity of sleep does not change, but the hours in which it occurs may.
This change can prove frustrating for older adults who find themselves
nodding off during evening activities and wide awake in the early morning
hours when everyone else is asleep. In addition, daytime naps may be
needed to compensate for reductions in nighttime sleep. Adjusting
schedules to accommodate the altered biorhythms could prove useful.
Increasing natural light is also useful in pushing the circadian rhythm
toward a later hour of sleep.
Sleep Stages
For sleep to be most restful, the person experiences a series of sleep stages.
Changes in the amount of time spent in each stage occur with aging (Table
12-2). Reductions in non–rapid eye movement stage sleep and rapid eye
movement (REM) stage sleep begin to occur after midlife. Older people
sleep less soundly, shift in and out of stage I sleep to a greater degree than
do younger adults, and spend more time in stages I and II sleep. They have
a decline in the proportion of time spent in the deeper stages III and IV
sleep.
TABLE 12-2 Stages of Sleep and Differences in Older

Adulthood
aCertain drugs can also decrease REM sleep, including alcohol, barbiturates, and phenothiazine
derivatives.

Sleep latency , a delay in the onset of sleep, is more prevalent with
advancing age. Beginning in midlife, people become more sensitive to
noise while they are sleeping and are awakened by noises that may not
cause a reaction in younger adults. Likewise, older individuals are more
likely than the young to be awakened by having lights turned on and having
changes in room temperature. It is important to consider these factors when
caring for older adults in institutional settings. If the sleeping area is noisy,
a white noise generator that produces soothing sounds that mask other
noises could prove useful. Some people find that a radio achieves the same
effect.
KEY CONCEPT
Nurses need to be aware that older adults can be easily awakened by
noise and lighting associated with caregiving and other staff activities
during the night.
SLEEP DISTURBANCES
Nearly half of the adult population complains of sleep disorders, with the
major complaint being insomnia. The nurse can assess for sleep
disturbances in the older adult by using a self-rating tool such as the
Pittsburgh Sleep Quality Index (see Online Resources at the end of this
chapter). In addition to insomnia, leg movements, sleep apnea, medical
conditions, and drugs can disturb sleep in older adults.
It is important that poor sleep quality be identified and addressed
because it could reveal other conditions and risks. Research has shown that
poor sleep quality can be associated with depression and heighten the risk
of suicidal ideation and suicide attempt (Owusu et al., 2020). In addition,
shorter sleep duration and restless sleep have been found to be associated
with higher levels of beta amyloid in the brain, which is a biomarker for
Alzheimer’s disease (Van Enum, Van Dam, & De Deyn, 2018).
Insomnia
Insomnia consists of difficulty falling or staying asleep and/or premature
waking. It can be difficult to get a fair estimate of the problem because
insomnia can have various meanings. People may report that they have
insomnia because they awaken at 5 am, have difficulty falling asleep, do not
sleep soundly, or travel to the bathroom several times during the night. This
reinforces the importance of recognizing insomnia as a symptom and
thoroughly assessing for factors that contribute to disrupted sleep. Insomnia
can be a short-term (transient) problem associated with a changed
environment, illness, added stress, or anxiety. Chronic insomnia (i.e.,
insomnia lasting 3 or more weeks) can be related to physical or mental
illnesses, environmental factors, substance abuse, or medications. Sedatives
may be unnecessary if the underlying cause of insomnia can be addressed.
COMMUNICATION TIP
During an assessment of sleep in older adults, if patients report
insomnia, nurses should explore the specifics to clarify if the problem
is an insufficient quantity of sleep or a poor quality of sleep. Asking
patients about specific factors that could affect sleep can allow
patients to remember factors that could contribute to their insomnia
that they may not have thought about before. Such factors could
include drinking a cup of tea that contains caffeine before bedtime or
not using an effective analgesic to control their pain.
Nocturnal Myoclonus and Restless Legs

Syndrome
Jerking leg movements during sleep can cause awakenings during the night.
One such cause of this is known as nocturnal myoclonus , a condition
characterized by at least five leg jerks or movements per hour during sleep.
Nocturnal myoclonus is associated with the use of tricyclic antidepressants
and chronic renal failure.
Restless legs syndrome , a neurological condition characterized by an
uncontrollable urge to move the legs, increases in incidence and severity
with age. People with restless legs syndrome may describe the sensations
with terms such as “uncomfortable,” “electrical,” “itching,” “pins and
needles,” “pulling,” “creepy-crawly,” and “painful.” Moving the legs brings
relief of the sensations but also interferes with sleep. It can be caused by
iron deficiency anemia, uremia, Parkinson’s disease, rheumatoid arthritis,
diabetes, or neurological lesions; it is believed to be associated with
alterations in dopamine and iron metabolism. Antidepressants,
antihistamines, antipsychotics, alcohol, and hypoglycemia can contribute to
this syndrome. Dehydration worsens symptoms; drinking a glass of water
may relieve symptoms for some individuals, as can massage and the
application of heat or cold.
Although the long-term effectiveness in older adults has not been
sufficiently studied, both nocturnal myoclonus and restless legs syndrome
are treated with dopaminergic drugs, benzodiazepines, opioids,
anticonvulsants, adrenergics, and iron supplements.
Sleep Apnea
Sleep apnea is a significant disorder in which at least five episodes of
cessation of breathing, lasting at least 10 seconds, occur per hour of sleep,
accompanied by daytime sleepiness. It is characterized by snoring and
sudden awakening and gasping for air. The prevalence is three times greater
in men than in women and higher in persons who are overweight or obese.
This disorder can be caused by a defect in the central nervous system
that affects the diaphragm (central sleep apnea), a blockage in the upper
airway that interferes with normal air flow (obstructive sleep apnea), or a
combination of both (mixed). Snoring usually accompanies the obstructive
type. The interruption of sleep can result in daytime fatigue and sleepiness;
nurses should assess for sleep apnea when these symptoms are present.
Sleep disorder clinics and other resources can assist in evaluating the
disorder and determining the best treatment plan, which could consist of
weight reduction, medications, continuous positive airway pressure, and/or
surgery to remove obstructions or realign bite.
Sleeping in a supine position should be avoided because it allows the
tongue to fall back and block the airway. Alcohol and other drugs with
depressant effects can aggravate the problem by decreasing respiratory
drive and relaxing throat muscles. Patients need to be cautioned about
driving and using machinery if daytime drowsiness is present.

Health conditions, particularly chronic diseases, can interfere with sleep by
producing symptoms such as nocturia, incontinence, pain, orthopnea, apnea,
muscle cramps, and tremors. Cardiovascular conditions that produce
nocturnal cardiac ischemia can interfere with sleep due to the dyspnea and
transient angina that occur. Fluctuating blood glucose levels can interfere
with the sleep of persons who have diabetes. Gastric pain can awaken
persons with gastroesophageal reflux disease. Chronic obstructive
pulmonary disease and other respiratory conditions can disrupt sleep with
coughing and dyspnea. Musculoskeletal conditions can cause pain. People
with dementia have minimal stage II and REM sleep, no stage IV sleep, and
frequent arousals from sleep. Depression and other emotional disturbances
can alter sleep.
Because medical conditions can affect sleep, it is important to consider
that changes in sleep patterns may indicate signs of other undetected
problems in older persons. Although early morning rising is not unusual for
older adults, a sudden change to earlier awakening or insomnia may be
symptomatic of an emotional disturbance or alcohol abuse. Sleep
disturbances also may arise from cardiac or respiratory problems, which
produce difficulties, such as orthopnea and pain related to poor peripheral
circulation. Restlessness and confusion during the night may indicate an
adverse reaction to a sedative. Nocturnal frequency may be a clue to the
presence of diabetes. It is important to assess both the quality and quantity
of sleep.

Like medical conditions, medications used to treat those conditions can
affect sleep. Older adults experiencing sleep problems should identify and
review their medications with their physicians. Examples of drugs that can
interrupt sleep include anticholinergics, antidepressants, antihypertensives
(centrally acting ones), benzodiazepines, β-blockers, diuretics, levodopa,
steroids, theophylline, and thyroid preparations. Hypnotics interfere with
REM and deep sleep stages and can cause daytime drowsiness (due to their
extended half-lives in older people), thereby creating difficulties in falling
asleep for the patient.
Examples of specific drugs that affect sleep include diphenhydramine
HCl (Benadryl capsules); nicotine (NicoDerm nicotine transdermal system);
fluoxetine HCl (Prozac); theophylline (Theo-X Extended-Release tablets);
and alprazolam (Xanax). Many of the top nonprescription sleep aids contain
diphenhydramine (Benadryl) as a primary ingredient; because Benadryl
carries a high risk of anticholinergic side effects in older adults, these
should be avoided.
Sleep can be interrupted by nightmares caused by drugs, particularly
those that affect neurotransmitters. These include some antianxiety drugs,
antidepressants, antihistamines, β-blockers, analgesics, antiparkinson drugs,
sedatives, smoking cessation aids, statins, and drugs used in the treatment
of dementia. If the patient reports having nightmares, a review of
medications could prove useful.
Caffeine and alcohol can also negatively affect sleep. Eliminating
caffeine and alcohol is advisable if sleep disorders are present. Nurses can
educate older adults about the caffeine content of food and beverages.

An apartment located on a busy street, a snoring spouse, an excessively
warm room, and bright hallway lights of a nursing home are among the
examples of environmental factors that can interfere with sleep. Adjusting
to a new environment, as can occur when one relocates to an assisted living
community or the home of a child, can affect sleep. Caffeine and alcohol
consumption can impair the ability to fall asleep and achieve a satisfying
quality of sleep. Pain and other symptoms (e.g., dyspnea when supine) can
cause problems falling and staying asleep, as can an uncomfortable
mattress. Exploring these issues when sleep problems are present is an
important part of the sleep assessment.
PROMOTING REST AND SLEEP IN
OLDER ADULTS
Every assessment needs to include a sleep history, which includes
Review of time spent in sleep and naps, quality of sleep

Medication review
Bedtime routines
Presence of sleep disturbances, if present:
Length of time present
Characteristics (e.g., falling asleep, staying asleep, and early
awakening)
Type of bedding and sleep environment
Food and fluid consumed several hours prior to bedtime
Medications used to address sleep disturbances
Factors interfering with sleep (e.g., pain, voiding, and nightmares)
Effects (e.g., daytime drowsiness, irritability, and fatigue)
Management
When an older adult is experiencing a disturbed sleep pattern, the nurse

plays an important role in identifying ways to improve sleep (see Nursing
Problem Highlight 12-1). Plans may involve pharmacologic and
nonpharmacologic measures to promote sleep and measures to control pain.

SLEEP DEFICIENCY
Overview
A sleep deficiency exists when the quantity or quality of sleep negatively
affects daily function. This problem can be displayed by difficulties falling
or staying asleep, nighttime sleep of less than 4 hours, daytime
drowsiness, frequent yawning, lack of energy or motivation to engage in
activities, dark circles under eyes, weakness, and disturbances in mood or
cognition.
Age-related decrease in stage IV sleep, nocturia, muscle cramps,
orthopnea, dyspnea, angina, poor peripheral circulation, cough,
incontinence, diarrhea, insufficient activity or exercise, immobility, pain,
new environment, depression, confusion, anxiety, medications (e.g.,
antidepressants, antihypertensives, tranquilizers), noise, interruptions, high
caffeine consumption.
Goals
The patient will:
Obtain 7 to 8 hours of sleep daily

Be free from symptoms and signs associated with deficient sleep
Interventions
Assess sleep pattern. Ask the patient about number, length, and
quality of naps; activity pattern; bedtime; quality of sleep; awakening
time; and symptoms and interruptions of sleep. Attempt to identify
and correct factors associated with sleep disturbance.
Increase daytime activity; limit naps and reduce caffeine.
Consult with physician regarding eliminating medications that are
known to disrupt sleep.
Maintain bedroom temperature between 70°F (21°C) and 75°F
(24°C); control interruptions; provide a night-light.
Assist patient with toileting at bedtime. Be aware that renal
circulation improves when one lies down; therefore, the patient may
need to toilet shortly after going to bed.
Use measures that are known to stimulate sleep, such as soft music,
television, and drinking warm milk.
Avoid prebedtime exposure to smartphone and television screens.
Offer back rubs, evening care, and other comfort measures to relax
the patient and induce sleep.
Instruct the patient in measures to improve sleep.
If sedatives are necessary, use those that are least disruptive to sleep
cycle and monitor 24-hour effects from the drug.
Reduce the potential for injury by having bed in lowest position,
using side rails, providing night-light, adjusting lighting so that
patient does not have to travel from dark bedroom to bright
bathroom, encouraging patient to ask for assistance with transferring
and ambulating as needed.
Record or have the patient record sleep pattern (e.g., time to bed, time
when asleep, times awakened during the night, signs and symptoms
during sleep, rising time, self-assessment of restfulness).

Older adults often have difficulty falling asleep. Unfortunately, frequently
the first means used to encourage sleep is the administration of a sedative.
Sedatives must be used with the utmost care. Barbiturates are general
depressants, especially to the central nervous system, and they can
significantly depress some vital body functions, lowering basal metabolic
rate more than it already is and decreasing blood pressure, mental activity,
and peristalsis to the extent that other problems may develop. These serious
effects, combined with a greater susceptibility to adverse reactions, warrant
that barbiturates be used with extreme caution. Nonbarbiturate sedatives
also create problems and should be used only when absolutely necessary.
Because of the prolonged half-life of medications in older persons, the
effects of sedatives may exist into the daytime and result in confusion and
sluggishness. Sometimes these symptoms are treated with medications,
further complicating the situation. Occasionally, sleeping medications will
reverse the normal sleep rhythm. All sedatives may decrease body
movements during sleep and predispose the older person to the many
complications of reduced mobility.

Alternatives to sedatives should be used to induce sleep whenever possible.
The nurse may assess the older person’s rest and activity schedules, sleep
environment, and diet to identify possible interventions.
Activity and Rest Schedules

The person’s activity schedule should first be evaluated. Satisfying, regular
activity promotes rest and relaxation (Fig. 12-1). If a person has been
inactive in a bed or wheelchair all day, most likely he or she will not be
sleepy at bedtime. Including more stimulation and activity during the day
may be a solution. In addition, yoga and other relaxation exercises have
been shown to improve sleep quality.
FIGURE 12-1 Daytime activity promotes nighttime sleep.
Greater amounts of rest are required by older people and should be

interspersed with periods of activity throughout the day. Many older adults
focus all their activity in the early part of the day so that they will have the
evening free. For instance, the early morning hours may be used for
household cleaning, marketing, club meetings, gardening, cooking, and
laundering; the evening hours may then be spent watching television,
reading, or sewing. This pattern may be an outgrowth of decades of
employment, whereby one worked during the day and relaxed in the
evening. Older people need insight into the advantages of pacing activities
throughout the entire day and providing ample periods for rest and naps
between activities. The nurse may find it useful to review the older person’s
daily activities hour by hour and assist in developing patterns that more
equally distribute activity and rest throughout the day.
Furthermore, the amount of time allotted for sleep must be evaluated.
One should not expect the older person who goes to bed at 8 pm to be able
to sleep until 8 am the following day.
Increasingly, older adults are using computers and smartphones.
Because blue light and the brightness of the screen can suppress the natural
production of melatonin and interfere with sleep (Heo et al., 2017),
television, smartphone, and computer screen viewing should be limited
prior to bedtime to prevent interference with sleep.
Environment
Exposure to sunlight during the day can facilitate sleep at night. A warm
bath at bedtime can promote muscle relaxation and encourage sleep, as can
a back rub, a comfortable position, and the alleviation of pain or discomfort.
A room temperature preferred by the individual should be provided. Flannel
sheets and electric blankets can promote comfort and relaxation; electric
blankets should be used to preheat the bed and should be turned off when
the individual enters the bed to reduce the health hazards associated with
electromagnetic fields.
Environmental noise should be controlled. Often, nursing staff become
accustomed to noises on the nursing unit (e.g., carts rolling down the hall,
telephones ringing, staff conversations) and overlook the disruption to
residents’ sleep that these noises can produce. The World Health
Organization recommends that inpatient facilities have sound levels at night
that are below 35 decibels. Free smartphone noise-level apps are available
online (see, e.g., https://apps.apple.com/us/app/niosh-sim/id1096545820
and https://play.google.com/store/apps/details?
id=com.gamebasic.decibel&hl=en_US).
Food and Supplements

Foods high in carbohydrates tend to raise the level of serotonin in the brain,
which could have a sedating effect; therefore, a protein and carbohydrate
snack at bedtime may encourage sleep. Valerian root tea or herbal tincture
consumed 45 minutes before bedtime can also facilitate sleep. The
supplement melatonin (a synthetic form of the hormone that is naturally
stimulated by darkness) has gained popularity for improving the quality of
sleep in adults of all ages by correcting imbalances in the body’s circadian
rhythm. Because melatonin supplements may interact with
immunosuppressants, antidepressants, antipsychotics, warfarin, and other
medications, it is wise for the pharmacist and physician to review the safety
of using melatonin in combination with medications.
KEY CONCEPT
Regular exercise, exposure to sunlight during the day, and
noncaffeinated herbal teas at bedtime are three measures to help older
adults fall asleep naturally.
Stress Management
Stress is a normal part of life, but it can interfere with rest and sleep. Most
individuals confront a variety of physical and emotional stressors daily,
such as temperature changes, pollutants, viruses, injury, interpersonal
conflicts, time pressures, fear, bad news, and unpleasant or difficult tasks.
Many real or perceived threats to our physical, emotional, and social well-
being and balance can create stress. Demands and activity levels are not
necessarily correlated with stress; for example, a busy schedule or
numerous responsibilities to juggle may be less stressful than a boring,
monotonous existence.
CONSIDER THIS CASE

Mr. and Mrs. E, both 83 years of age, live
alone in a busy, high-crime area of a large city. Mr. E has a mild dementia
but is able to function well with his wife’s assistance and supervision.
Over the past year, however, he has had significant changes in his sleep
pattern in which he awakens several times during the night to use the
bathroom and sleeps most of the day. He has a tendency to drink
caffeinated sodas when he awakens if his wife doesn’t stop him, so she
often will get out of bed when he does to make sure he drinks caffeine-free
liquids. Mrs. E’s frequent awakening with her husband compounds a long-
term problem she has had with getting out of bed when she hears any
street sound to assure no one is breaking into their home. Mrs. E is not
comfortable napping during the day and tends to feel tired most of the
time.
THINK CRITICALLY
1. What risks do their sleep patterns present for Mr. and Mrs. E?
2. What recommendations would you have for this couple?
Regardless of the source of the stress, the body reacts by stimulating the
sympathetic nervous system. This causes stimulation of the pituitary gland,
the release of adrenocorticotropic hormone, and an increase in the body’s
adrenaline supply.
KEY CONCEPT
Unrelieved chronic stress can lead to heart disease, hypertension,
cerebrovascular accident, ulcers, and other health disorders.
Although avoiding stress is unrealistic for most individuals, it is

important to prevent chronic stress from developing. The key to stress
control is managing it by learning compensatory measures. Some of these
measures are outlined as follows:
Respond to stress in a healthy manner. Good nutrition, rest, exercise,

and other sound health practices strengthen the body’s ability to
confront stress. When in a stressful situation, adherence to these
principles continues to be important. It is beneficial to learn to remain
calm when faced with stress; reacting in an unhealthy manner worsens
the situation.
Manage lifestyle. Little in the lives of most people would bring the
world to a halt if not completed at a certain time or in a specific
manner. Things should be put in perspective; for example, what
difference will it really make if the clothes are not washed today or if
one is 10 minutes late? Whenever possible, anticipate the
consequences of a situation so that the stress of an unpredictable
situation can be reduced.
Relax. Be it a good book, swimming, weaving, travel, music, or wood
carving, find something in which to get absorbed so that there is some
respite from life’s demands. Yoga, meditation, qigong, guided imagery,
and relaxation exercises can be effective. Also, herbs can be of benefit,
including chamomile and lavender to promote relaxation and
American ginseng to protect the body from the ill effects of stress.
Pray. People of faith look to a higher power with whom they can share
and understand life’s burdens. The “unloading” of one’s problems
during prayer can also be a rest-inducing activity in that it clears the
mind of the day’s stresses. Furthermore, the repeated words or rituals
associated with prayer can offer the same therapeutic benefits as
meditation and relaxation exercises.
POINT TO PONDER
What are the three major stresses in your life? What are you doing to
minimize their negative effects? What more could you be doing to
control stress in your life?
Pain Control
The presence of pain can threaten the ability of older adults to obtain
adequate rest and sleep. Although the results of studies regarding the effects
of aging on pain sensitivity are inconclusive, the prevalence of chronic
pain–causing conditions, such as osteoarthritis and postherpetic neuralgia,
is high among older adults. Not only can pain interfere with sleep but it can
also reduce activity levels, depress mood, and result in other factors that can
affect sleep and rest patterns.
Identifying the cause of pain is the essential first step to controlling it.
Undiagnosed medical conditions can be the source of the problem, but so
can psychological factors, poor positioning, and adverse drug reactions. A
comprehensive assessment is crucial. Consideration should be given to
factors that precipitate, aggravate, and relieve pain. Nurses can assist
patients in self-evaluating pain with the use of rating scales that use
numbers or diagrams to indicate severity of pain (see Chapter 13).

For an older client who suffers from chronic pain, such as pain from
arthritis, taking pain medication at bedtime will eliminate the pain that is
preventing the client from getting adequate rest. Although other strategies,
such as avoiding caffeine 30 minutes before bedtime, might help, they do
not address the pain the client is experiencing and its interference with
sleep.
Because of the risks associated with drugs, nonpharmacologic measures
to control pain should be attempted whenever possible. Among these
measures are proper positioning, diversional activities, guided imagery,
biofeedback, yoga, massage, therapeutic touch, acupuncture, and magnet
therapy. If nonpharmacologic means of pain relief are ineffective and drugs
are necessary, it is advisable to begin with the weakest type and dosage of
analgesic and gradually increase as necessary. See Chapter 13 for more
information on pain management.
KEY CONCEPT
Massages, warm soaks, relaxation exercises, guided imagery, and
diversion can provide effective relief of many types of pain.

Sleep and Self-Rated Health in an Aging Workforce
Source: Coombe, A. H., Epps, F., Lee, J., Chen, M. L., Imes, C. C. &
Chasens, E. G. (2019). Workplace Health and Safety , 67 (6), 302–310.
This study explored the relationship between nonrestorative sleep and
work performance in employed adults 50 to 65 years of age. Factors such as
concentration, productivity, and sleep characteristics were examined.
Participants reported frequent insomnia and other sleep impairments. The
sleep problems of these individuals were associated with difficulty
organizing work, lower productivity, higher frequency of mistakes, and
other indications of reduced work performance.
The growing rate of employment of middle-aged and older adults, along
with the higher rate of sleep problems that occur with age, could cause
challenges in the ability of these individuals to maintain employment. In
turn, this could result in them forfeiting meaningful roles, activities, and
finances that contribute to their quality of life. In addition, poor
concentration and other problems resulting from impaired sleep could
increase the risk of injury to these workers. Therefore, frequent assessment
of sleep and review of performance issues (e.g., ability to concentrate,
frequency of mistakes, work output as compared to coworkers) are useful
for employed older adults. The nurse can provide education that explains
the relationship between sleep and work performance and can assist aging
workers who have sleep problems with identifying interventions that can
provide an adequate quality and quantity of sleep.
PRACTICE REALITIES
One of the hospital’s units is dedicated to people who are out of immediate
crisis but in need of close observation and treatment for several weeks. It is
not uncommon for vital signs to be checked and treatments performed at
any time around the clock. The busyness of the unit resembles an intensive
care unit.
The nurses have noted that older patients in particular have difficulty
sleeping, display high levels of fatigue during the day, and often experience
delirium. They believe interruptions to sleep are a major contributing factor.
What can the nurses do to assist older patients in obtaining adequate
rest and sleep while still attending to their critical care needs?

1. What nonpharmacologic measures can be incorporated into an older
adult’s lifestyle to facilitate sleep?
2. What stresses do older adults face that are different from those
encountered by other age groups?
questions.
The nurse is caring for a 72-year-old male resident that lives in a long-
term care facility.
Nurse’s Notes
0830: The nurse notes during breakfast in the dining room that the
resident is nodding off with his meal untouched. When awakened, he
becomes frustrated and combative, saying, “Leave me alone; I don’t
sleep at night.” The nurse encourages him to stay awake and finish eating
his breakfast.
The resident indicates that he finds it difficult to fall asleep because
his legs keep jerking and he has an uncontrollable urge to move his legs.
He says that when he finally falls asleep, he is awakened with an urge to
use the bathroom because of the water pills he takes. Upon assessment,
the resident says, “I only sleep about 2 hours a night.”
The nurse documents the following: The resident is on 20 mg of
furosemide twice a day (9 a.m. and 9 p.m.) for congestive heart failure
(CHF) as evidenced by his shortness of breath (SOB); the resident gets
only 2 hours of quality sleep every night; the resident drinks 1 cup of
caffeinated coffee at 6 p.m. every evening and is frequently observed
falling asleep at meals.
Chapter Summary
The aging process affects sleep in many ways. Older adults tend to fall
asleep and wake up earlier than in younger years, sleep less soundly, and
experience a reduction in stage IV sleep.
Insomnia, nocturnal myoclonus, restless legs syndrome, and sleep
apnea are among the most common disturbances to the sleep of older adults.
In addition, conditions that cause nocturia, incontinence, pain, muscle
cramps, and dyspnea can interfere with the quality and quantity of sleep, as
can noise and the effects of certain medications. The variety of factors that
can affect sleep requires that a thorough sleep history be done as part of the
comprehensive assessment.
A variety of measures can be used to promote sleep, including
adjustment to activities and nap times, limitation of caffeine consumption,
soft music, back rubs, decaffeinated herbal teas, stress management, and
control of noise and lighting. Sedatives need to be used with utmost care
due to their high risk for adverse effects in older adults.
Online Resources
American Sleep Apnea Association
http://www.sleepapnea.org
Hartford Institute of Geriatric Nursing
Try This: Best Practices in Nursing Care to Older Adults, The Pittsburgh
Sleep Quality Index
https://consultgeri.org/try-this/general-assessment/issue-6.1.pdf
National Institute of Neurological Disorders and Stroke
Brain Basics: Understanding Sleep
https://www.ninds.nih.gov/Disorders/Patient-Caregiver-
Education/Understanding-Sleep
National Sleep Foundation
http://www.sleepfoundation.org
Restless Leg Syndrome Foundation
http://www.rls.org
References
Heo, J. Y., Kim, K., Fava, M., Mischoulon, D., Papakostas, G. I., et al. (2017). Effects of smartphone
use with and without blue light at night in healthy adults. A randomized, double-blind, cross-
over, placebo-controlled comparison. Journal of Psychiatric Research , 87 (4), 61–70.
Li, J., Vitiello, M. V., & Gooneratne, N. S. (2018). Sleep in normal aging. Sleep Medicine Clinics , 13
(1), 1–11.
Owusu, J. T., Doty, S. B., Adjaye-Gbewonyo, D., Bass, J. K., Wilcox, H. C., et al. (2020).
Association of sleep characteristics with suicide ideation and suicide attempt among adults aged
50 and older with depressive symptoms in low- and middle-income countries. Sleep Health , 6
(1), 92–99. Retrieved January 29, 2020 from
https://www.sciencedirect.com/science/article/abs/pii/S2352721819301846?via%3Dihub
Van Enum, J., Van Dam, D., & De Deyn, P. P. (2018). Sleep and Alzheimer’s disease: a pivotal role
for the suprachiasmatic nucleus. Sleep Medicine Reviews , 40 , 17–27.
CHAPTER 13
Comfort and Pain Management
Chapter Outline
Comfort
Pain: A Complex Phenomenon
Prevalence of Pain in Older Adults
Types of Pain
Pain Perception
Pain Assessment
An Integrative Approach to Pain Management
Dietary Changes
Medication
Comforting
LEARNING OBJECTIVES
1. Define comfort.
2. Describe the characteristics and effects of pain in older adults.
3. Describe the components of a comprehensive pain assessment.
4. Outline components of a pain management plan, including
complementary therapies, dietary changes, medications, and
comforting strategies.
TERMS TO KNOW
Acute painabrupt onset and lasting a short time
Neuropathic painoccurs from an abnormal processing of sensory stimuli
by the central or peripheral nervous system
Nociceptive painarises from mechanical, thermal, or chemical noxious
stimuli; can be somatic or visceral
Persistent or chronic painchronic pain that has been present for 3
months or longer
COMFORT
Comfort is a relative term. To some people, it can mean sufficient control of
pain to capture a few hours of rest; other individuals may view comfort as
freedom from physical and mental stress; and still others may consider
luxurious, pampered living synonymous with comfort. The word comfort is
derived from the Latin word confortare, which means to strengthen greatly.
From a holistic perspective, comfort can be viewed as a sense of physical,
emotional, social, and spiritual peace and well-being.
Comfort tends to be a state often taken for granted until it is threatened.
People coast along without pain or distress, not giving much thought to the
comfort they are experiencing. But then something happens—unrelenting
gastric pain develops; joints ache while doing routine tasks; a suspicious
lump is found in a breast—and the comfort cart is upset. Unfortunately,
with advancing age, the incidence of factors that can threaten comfort
increases.
PAIN: A COMPLEX PHENOMENON

Pain is the greatest threat to comfort. For decades, pain was described as
“an unpleasant sensory and emotional experience associated with actual or
potential tissue damage,” implying that there had to be objective cause for
the pain. It is now accepted that pain is subjective and relies on the patient’s
perception and description.
KEY CONCEPT
Although health care professionals do not want to place too much focus
on pain and risking excess or unnecessary opioid use, assessment of pain
is an important consideration in every assessment.
PREVALENCE OF PAIN IN OLDER

ADULTS
Although more than half of older adults report having pain on a daily basis,
it may be difficult to determine the accuracy of the reported prevalence of
pain in older persons (Hulla et al., 2019). On the one hand, older adults may
underreport pain because they do not want to be viewed as complainers,
lack the funds to seek treatment, or erroneously believe that pain is a
normal part of being old. On the other hand, pain could be overreported by
some older people who see reporting this symptom as an effective means to
get the attention of family members and health care professionals. These
possibilities reinforce the importance of exploring pain during every
assessment and reviewing the relationship of other factors (physical,
emotional, socioeconomic, and spiritual) to this symptom.
KEY CONCEPT
The complex phenomenon of pain is a stressor to physical, emotional,
and spiritual well-being.
Types of Pain
There are several ways in which pain is classified. One classification is by
the pathophysiological mechanism that causes it. The two main types that
arise from tissue damage are nociceptive pain and neuropathic pain .
Nociceptive pain arises from mechanical, thermal, or chemical noxious
stimuli to the A-delta and C afferent nociceptors. These nociceptors are
found in fasciae, muscles, joints, and other deep structures, and their
activation causes a transduction of painful stimuli along the primary
afferent fiber of the dorsal horn of the spinal column. Neurotransmitters
(e.g., somatostatin, cholecystokinin, and substance P) carry the pain signal
through secondary neurons to the brain where the signal is interpreted.
Common forms of nociceptive pain include the following:
Somatic pain: characteristic of pain in the bone and soft tissue masses.
The pain is well localized and described as throbbing or aching.
Visceral pain: associated with injuries or disorders of the internal
organs that can cause generalized or referred pain. The pain is
described as deep, cramping, pressing, and aching.
Neuropathic pain occurs from an abnormal processing of sensory

stimuli by the central or peripheral nervous system and is associated with
diabetic neuropathies, postherpetic neuralgias, and other insults to the
nervous system. The pain is sharp, stabbing, shooting, tingling, or burning,
with a sudden onset of high intensity. It can last a few seconds or linger for
a longer period.
Pain is also described according to its onset and duration. Acute pain
has an abrupt onset, can be severe, but lasts only a short time; it usually is
responsive to analgesics and other pain management approaches. Persistent
or chronic pain is that which has been present for 3 months or longer and
can be of mild to severe intensity. Acute pain has the potential to develop
into persistent pain.
Pain Perception
The role of age in pain perception is unclear. There is some evidence that
older adults are more sensitive than young adults to mechanically evoked
pain but not heat-evoked pain, but more research in this area is needed (El
Tumi, Johnson, Dantas, Maynard, & Tashani, 2017). Understanding the
effects of aging on the experience of pain is complicated by the chronic
diseases that are common in late life. For example, it could be that older
adults do not have reduced pain sensitivity but rather experience a
decreased transmission of signals associated with diseased tissues. Much
remains to be learned about the relationship of aging and pain perception.
KEY CONCEPT
The impact of aging on pain perception and tolerance is not fully
understood; therefore, the nurse must try to assess and understand each
patient’s unique pain experience.

Unrelieved pain can lead to many complications for older adults. For
example, if movement causes pain, the person may limit mobility and,
consequently, develop pressure ulcers, pneumonia, and constipation. The
individual experiencing pain may have a poor appetite or lack the
motivation to eat and drink properly; malnutrition and dehydration can
result. The experience of chronic or unrelenting pain can cause a person to
become depressed, hopeless, socially isolated, and spiritually distressed. To
provide adequate relief from pain and reduce the risk of complications,
effective pain management is essential.
POINT TO PONDER
Reflect on the worst pain you have experienced. How did that affect your
activities, relationships, and outlook?
PAIN ASSESSMENT
Effective pain management begins with qualitative and quantitative
assessment of this symptom. Inquiries into the presence of pain are an
essential component of every assessment. When patients indicate that they
experience pain, nurses can ask them to describe it through the use of
questions similar to those shown in Assessment Guide 13-1. Questions that
facilitate descriptive rather than yes-or-no answers offer better insights into
the pain experience. If medications are used for pain management, ask
specific questions about the type, dosage, frequency, and effectiveness. The
more detailed the pain history, the better the likelihood of developing an
effective pain management plan.

PAIN
MEDICAL HISTORY
Acute conditions
Chronic conditions
Cognitive status
Surgeries
Medications
Significant recent events (e.g., relocation, death of spouse, fall)
GENERAL OBSERVATIONS
Grimacing, crying, moaning, clutching fists
Limitations of movement, shifting position
Favoring or rubbing of specific body part
Discoloration
Swelling
Agitation, depression
INTERVIEW
Where is the pain located? Does it stay in one place or travel to other
locations?
What does it feel like? Stabbing? Throbbing? Aching? Dull? Sharp?
On a scale of 0 to 10, with 0 being no pain and 10 being unbearable
pain, how would you rate it as typically being? How would you rate it
when it is at its best? At its worst?
How frequently does it occur? Several times a day? Daily? A few
times a week? Every few weeks?
How long does it last? A few seconds? A few hours? All day?
Is the pain related to any medical problems, injuries, or unusual
events?
What factors seem to bring it on?
What factors worsen it? Activity? Weather? Stress?
Is it worse at certain times of the day?
What helps to relieve the pain? Medications? Positions? Special
treatments?
If medications are used, what are they, what is their dosage, how
are they taken, and what effects do they produce?
Are any complementary or alternative therapies used? If so, what,
how, and with what results?
How does the pain affect your life? Sleep? Appetite? Activity?
Socialization? Self-care? Home responsibilities? Relationships?
Range of motion
Sensitivity to touch, guarding
Temperature of affected area as compared with adjacent areas
Weakness, numbness
Swelling
Bruises, cuts
Inflammation
Physical examination offers additional insights into patients’ pain.

Painful areas identified during the interview should be examined for
discoloration, swelling, trigger points, and other signs. The nurse notes
sensitivity to touch and restricted movement to the area, along with body
language indicative of pain (e.g., grimacing, favoring a side, or rubbing an
area).
Ongoing assessment is essential to determine the status of the pain and
effectiveness of interventions.
Patients with cognitive impairments present special challenges to pain
assessment. These individuals may not have the ability to interpret or report
their symptoms; therefore, a greater burden falls on the nurse to adequately
identify and assess pain. A change in function, poor appetite, agitation,
sleep disruptions, or refusal to participate in care or activities could be
indications of pain. Asking caregivers or family members who are familiar
with patients’ norms about changes they may note can assist in detecting
even subtle changes in status that could be associated with symptoms of
pain. Box 13-1 lists signs that could indicate pain in persons who are
cognitively impaired. When such signs are identified, physical assessment
should be performed to detect signs of abnormalities (e.g., abnormal lung
sounds, abdominal sensitivity, reduced range of motion, bruised limb, etc.).
That patients with cognitive impairments do not offer specific complaints
does not mean they are free from pain. When the nurse identifies a patient’s
unique manifestations of pain, he or she should ensure they are well
documented in the health record for future reference in assessment.
BOX 13-1 Signs That Could Indicate Pain in

Persons With Cognitive Impairments
Grimacing
Crying, moaning
Increased vital signs
Perspiration
Increased pacing, wandering
Aggressive behaviors
Hitting, banging on objects
Splinting or guarding body part
Agitation
Poorer function
Change in sleep pattern
Change in appetite or intake
Decreased socialization
Cultural factors must also be considered during the pain assessment. In

some cultures, people may be socialized to tolerate pain without expression,
whereas in other groups, dramatic expression of pain may be the norm.
Likewise, some men may have been raised with the belief that “real men
don’t admit to pain” and may not acknowledge the severity of their
discomfort. These factors support that the nurse must be thorough and
astute when assessing pain.
Nurses must be sensitive to potential barriers to effective pain
assessment, which can include the following:
Knowledge deficits: Nurses may be unfamiliar with the altered

presentation of pain that can be present in some older adults or
presentation of pain in individuals with dementia.
Inadequate pain assessment: Not inquiring about the presence of pain
or using terms that may not have meaning for certain patients can
prevent pain from being identified. Failing to document signs and
symptoms of pain can prevent appropriate management.
Biases or assumptions: Some nurses may believe that patients are
exaggerating their symptoms or that patients’ complaints of pain are
not justified by their condition. Concern that patients may become
addicted to analgesics could cause nurses to reduce the administration
of these drugs.
Staffing issues: The lack of consistent staffing can prevent nurses from
identifying changes and new symptoms that are related to pain but that
patients don’t share. Likewise, having limited time with patients can
reduce the opportunities for patients to share symptoms.
A variety of pain assessment instruments provide standardized methods for
objectively evaluating pain such as the following:
Numeric Rating Scale. This commonly used tool asks the patient to
rate pain on a scale from 1 to 10, with 1 representing minimal pain and
10 the worst pain imaginable. It is important to assess the person’s
ability to understand and follow directions when using this scale.
Visual Analog Scale. This simple but effective pain assessment tool
uses a horizontal line with “no pain” on the left end and “pain as bad
as it can possibly be” on the right end. The patient indicates where his
or her pain falls on the scale. A modified version of this tool uses
faces, with 0 being a smile and 6 being a crying grimace.
McGill Pain Questionnaire. This popular and widely used tool
contains 78 words categorized into 20 groups, a drawing of the body,
and a Present Pain Intensity scale. This tool is effective for use with
persons who are either cognitively normal or impaired. Its length and
reliance on reading or hearing the items can pose problems with some
individuals.

The nurse should keep in mind that although some cognitively normal or
impaired clients might cry or moan, that is not a reliable indication of pain.
The McGill Pain Questionnaire is effective for use with persons who are
cognitively normal or impaired.
Barriers to using standardized tools must be considered. Patients need

to receive clear instructions and have an opportunity to practice using the
tool. Using the same tool consistently facilitates the collection of data that
are comparable and meaningful.
COMMUNICATION TIP
The fact that patients have not complained about pain does not
guarantee its absence in their lives. Pain sufferers may not inform their
physicians about their pain despite its impact on the quality of their
lives. The reality that many people attempt to live with pain reinforces
the importance of nurses inquiring about this symptom with routine
assessments. Asking specifically about pain can assist in triggering
patients’ memories and encouraging them to share pain symptoms
(e.g., Are your joints sore in the morning? Is there anything that
causes you discomfort? Is your sleep/activity/eating affected by pain?
Do you regularly take any medication for pain?).
AN INTEGRATIVE APPROACH TO
PAIN MANAGEMENT
Nurses can be influential in guiding the development of a pain management
plan that is individualized and comprehensive. Before implementing
symptomatic treatment, underlying causes for the pain need to be identified
and corrected as possible. Goals set the foundation for the interventions
planned and need to be realistic, specific, and achievable, for example:
Reduce pain level from 9 to 5 within the next 5 days

Obtain at least 5 hours of sleep without interruptions from pain
Independently bathe and dress without restrictions from pain within
the next week
KEY CONCEPT
In addition to medical problems, poor positioning or posture, inactivity,
emotional issues, and adverse drug reactions could be at the root of new
or worsened pain. Improving these underlying factors is the first step in
pain management.
Even if the underlying causes for pain cannot be identified or corrected,
nurses can still plan interventions to manage what may be chronic pain
(Nursing Problem Highlight 13-1). Common components of pain
management plans include complementary therapies, dietary changes,
medications, and comforting nursing care.

CHRONIC PAIN
Overview
Chronic pain is an uncomfortable sensation that persists and must be
managed on a long-term basis.
Arthritis, shingles, terminal cancer, phantom limb, depression,
ineffectiveness of analgesic
Goal
The patient will experience a reduction in or elimination of pain and safely
use effective pain relief measures.
Interventions
Perform a comprehensive assessment to assist in identifying the
underlying cause and nature of pain. Review pain relief measures
used and their effectiveness.
If the patient currently is not using one, instruct in the use of a scale
for self-assessment of pain.
Teach the patient and/or caregivers pain control measures such as
guided imagery, self-hypnosis, biofeedback, and yoga.
Discuss benefits of acupuncture, chiropractic, homeopathy, herbs, and
other complementary therapies with health care providers and refer
accordingly.
Assure analgesics are used properly.
Control environmental stimuli that may affect pain (e.g., loud noise,
bright lights, and extreme temperatures).
Use music therapeutically for relaxation.
Refer to resources for pain management, such as the American
Chronic Pain Association.
Monitor level of pain and continued effectiveness of pain relief
measures.
Although medications have a significant role in pain management, they
should not be the only approach used. Increasingly, therapies that once were
considered “alternative” or “unorthodox” are being used as complementary
approaches to pain management as part of effective integrative care. Using
this vision for added options to address pain, possible interventions that
could be used in a comprehensive pain management program include the
following:
Acupressure: Use of pressure over points along meridians (what in

traditional Chinese medicine are believed to be invisible channels of
energy [qi] running through the body) to unblock energy flow and
restore or promote the balance of qi
Acupuncture: Placement of needles under the skin at acupoints along
meridians to unblock energy flow and restore or promote the balance
of qi
Aromatherapy: Branch of herbal medicine that uses scents from the
essential oils of plants to create physiological and emotional effects
(e.g., use of lavender, geranium, rose, and sandalwood scents to calm)
Biofeedback: Process of teaching people to bring specific bodily
functions under voluntary control
Chiropractic: Use of manipulation or adjustment of the spine and
joints to correct misalignments that can be causing dysfunction and
pain
Electrical stimulation: Use of electrical currents administered to the
skin and muscles via electrodes placed on the painful part of the body
Exercises: Gentle stretching and range of motion exercises
Guided imagery: Suggesting images that can create specific reactions
in the body
Heat and cold therapies: Use of hot or cold pads, packs, dips (e.g.,
paraffin), baths, massage, or environments (e.g., sauna)
Herbal medicine: Use of plants for therapeutic benefit (Box 13-2)
Homeopathic remedies: Use of dilute forms of biological material
(plant, animal, or mineral) that produce symptoms similar to that
caused by the disease or condition
Hypnosis: Guiding person into trancelike state in which increased
receptivity to suggestion is possible
Massage: Manipulation of soft tissue by using rubbing, kneading,
rolling, pressing, slapping, and tapping movements (called bodywork
when combined with deep tissue manipulation, movement awareness,
and energy balancing)
Meditation: Using deep relaxation to calm the body and mind and
focus on the present
Naturopathy: Use of proper nutrition, pure water, fresh air, exercise,
rest, and other natural means
Osteopathy: Branch of physical medicine that uses physical therapy,
joint manipulation, and postural correction
Prayer: Petition to God or other divine power through direct or
intercessory praying
Progressive relaxation: Series of exercises that help the body achieve a
state of deep relaxation
Supplements: Use of specific nutritional products (e.g., B-complex
vitamins to enhance function of nervous system; bromelain, fish oil,
ginger, turmeric, and devil’s claw to reduce inflammation; topical
capsaicin to block pain signal; feverfew and vitamin B2 to reduce
migraines)
Touch: Therapeutic touch (TT) and healing touch (HT) are forms of
energy healing in which the caregiver places hands over various parts
of the patient’s body to manipulate the patient’s energy field (Box 13-
3)
BOX 13-2 Herbs Used for Pain Management

Because many herbs can interact with medications, the nurse should
consult with a herb-knowledgeable professional before suggesting the
use of any herb. Herbs commonly used to help manage pain include the
following:
Capsaicin/capsicum (chili pepper oil): used topically for joint and

nerve pain; relief provided within a few days
Devil’s claw: effective for inflammatory-related pain, such as
rheumatoid arthritis; taken orally in dried or extract form; can take
several weeks to work
Feverfew: beneficial for prevention of migraines; used orally; best
to take in capsule or extract form because plant leaves can be highly
irritating to the mouth
Ginger: reduces inflammation and nausea
Turmeric: useful with inflammatory conditions
Valerian: relaxes muscles; has a mild sedative effect
White willow: relieves inflammation and general pain
BOX 13-3 The Use of Touch for Comfort

Touch has been a means of providing comfort since the earliest of times.
In addition to its therapeutic benefits, physical contact through the act of
touch conveys caring and warmth, which promotes emotional comfort
and well-being. A variety of modalities use some form of touch to
promote comfort that nurses can learn; these include the following:
ACUPRESSURE
A major therapy within traditional Chinese medicine that has existed for
over 2,000 years, acupressure uses the application of pressure to specific
points on the body. It is based on the belief that there are invisible
channels throughout the body called meridians, through which energy
(qi) flows. It is believed that illness and symptoms develop when the
flow of energy becomes blocked or imbalanced. Placing pressure on the
points that correspond to the part of the body experiencing discomfort
can bring relief. For example, placing pressure for a few minutes on the
depressions at the base of the skull about 2 in. from the middle of the
neck can offer relief from headache pain.
MASSAGE
Massage is widely used as a means to promote comfort and relaxation. It
consists of the manipulation of soft tissue by rubbing, kneading, rolling,
pressing, slapping, and tapping movements. In addition to back rubs,
hand and foot massages can promote relaxation, rest, and comfort.
TOUCH THERAPIES
Therapeutic touch (TT) and healing touch (HT) are popular
complementary therapies used by nurses to relieve pain, reduce anxiety,
and enhance immune function. TT became popular in nursing in the
1970s with the work and research of Delores Krieger who advanced the
theory that people are energy fields and that obstructed energy could be
responsible for unhealthy states. By drawing on the universal field of
energy and transferring this energy to the patient, the patient’s own inner
resources for healing could be mobilized. Although the word touch is
used in its title, TT actually involves minimal physical contact. Instead,
the nurse passes his or her hands over the client’s body to assess the
energy field and mobilizes areas in which energy is blocked by directing
energies to that area.
HT is an offshoot of TT that incorporates additional healing approaches
to the basic ones of TT to open energy blockages, seal energy leaks, and
rebalance the energy field. There is a six-level educational program for
HT.
For more information on these therapies, see related associations
listed under Online Resources.
POINT TO PONDER
What methods, other than medications, do you use to manage pain?
What facilitates or limits your use of complementary and alternative pain
management approaches?
Nurses need to be knowledgeable about the uses and contraindications
of various therapies to be able to offer guidance to patients. Also, nurses
should be familiar with the licensing requirements for various
complementary and alternative practitioners and assist patients in locating
qualified therapists. Education and counseling are important to ensure
patients make informed choices about their therapists. The National Center
for Complementary and Integrative Health’s Web site provides evidence-
based information that can assist in assuring safe use of these therapies.
Dietary Changes
Diet can influence inflammation and its pain, particularly arthritic pain that
is common in the older population. Arachidonic acid is a primary precursor
in the synthesis of omega-6 to proinflammatory eicosanoids. Therefore,
eliminating foods that contain arachidonic acid or that are converted into
arachidonic acid can be beneficial to persons who suffer from inflammatory
conditions. Foods to consider avoiding include animal products, high-fat
dairy products, egg yolks, beef fat, safflower, corn, sunflower, soybean, and
peanut oils. White flour, sugars, and “junk foods” also are believed to
contribute to inflammation.
A deficiency of B-complex vitamins can contribute to pain caused by
damaged or misfiring nerves. Consuming green leafy vegetables can
provide B-complex vitamins, along with chemicals that enhance serotonin.
In addition, some foods can reduce or protect against inflammation.
Foods rich in omega-3 fatty acids can reduce inflammation; these include
cold-water fish (e.g., salmon, tuna, sardines, mackerel, and halibut) and
their oils, flaxseed and flaxseed oil, canola oils, walnuts, pumpkin seeds,
and omega-3 enhanced eggs. Antioxidants offer protection against
inflammation, and chief among them are flavonoids. Flavonoids inhibit
enzymes that synthesize eicosanoids, thereby interfering with the
inflammatory process. Sources of flavonoids include red, purple, and blue
fruits, such as berries and their juices; black or green tea; red wine;
chocolate; and cocoa. Fresh pineapple also is considered helpful in reducing
inflammation. The herbs garlic, ginger, and turmeric (the main ingredient in
curry powder) also are believed to have anti-inflammatory effects.
Medication
Using medications to manage pain in older adults can be complicated
because of the high number of drugs this age group consumes and unique
pharmacokinetics and pharmacodynamics (see Chapter 15). The risk of
adverse effects is higher than in younger age groups, but this should not
deter analgesic use in older adults. Rather, analgesics need to be used
appropriately and monitored closely.
If nonpharmacologic means of pain relief are ineffective and drugs are
necessary, it is advisable to begin with the weakest type and dosage of
analgesic and gradually increase as necessary. Trials of nonopioids should
be used before resorting to opioids. Adjuvant drugs (e.g., tricyclic
antidepressants, anticonvulsants, antihistamines, and caffeine) can be useful
in the control of nonmalignant pain or in combination with opioid drugs.
Narcotics should be used discriminately in older persons because of the
high risk of delirium, falls, decreased respirations, and other side effects.
Administering a nonnarcotic analgesic with the narcotic could decrease the
amount of narcotic that is needed. Analgesics should be administered
regularly to maintain a constant blood level; fear of addiction should not be
a factor in appropriately using analgesics to assist patients in achieving
relief. It is recommended that meperidine, indomethacin, pentazocine, and
muscle relaxants not be used for pain relief in older adults due to the high
risk of adverse effects (2019 American Geriatrics Society Beers Criteria
Update Expert Panel, 2019).
Acetaminophen is the most commonly used drug for mild to moderate
pain relief in older people, followed by nonsteroidal anti-inflammatory
drugs (NSAIDs), with ibuprofen the most used of this drug group. Before
advancing to an opioid analgesic, the patient should try a different NSAID.
For moderate to severe pain, opioids of choice include codeine, oxycodone,
and hydrocodone; these are available in combination with nonopioids to
enhance benefits from the additive effect. Morphine and fentanyl patches
are used for severe pain.
Pentazocine is contraindicated for older persons because of its high risk
of causing delirium, seizures, and cardiac and CNS toxicity.
Opioid use among older adults has been increasing, along with negative
effects related to its use and misuse. Older adults are more likely to
experience nausea, constipation, urinary retention, pruritus, myoclonus,
irregular breathing, and cognitive dysfunction from opioids (Aging in Place,
2020). Addiction also is a risk.
Nurses should closely observe responses to medications to determine if
the drug and its schedule of administration are appropriate. Around-the-
clock dosing or the use of sustained-release drugs is useful in the
management of continuous pain. If at all possible, medications should be
administered on a schedule to prevent pain, rather than treat it after it
develops.
Regular reevaluation of patients’ response to medications is essential.
Medications may change in their effectiveness over time, necessitating a
change in the prescription. Also, side effects and adverse reactions can
develop with drugs that have been used for a long time without incident.
CONSIDER THIS CASE
Sixty-six-year-old Mr. O’Day is visiting

the office of his primary physician for an annual exam. During the
assessment, the nurse learns that Mr. O’Day has significant joint
restrictions in his lower extremities due to arthritis and the consequences
of a poorly healed fracture. When asked about related pain, Mr. O’Day
seems evasive and responds, “I manage it.” He is vague when the nurse
questions how he manages it. “I’ve got it under control,” he states.
The nurse steps outside the examining room to afford Mr. O’Day
privacy in undressing and is approached by Mrs. O’Day. “He’s probably
not going to tell you,” his wife says, “but he has some pretty bad pain in
his hips and knees, and he deals with it by buying marijuana and pain pills
from some guys in the neighborhood. Sometimes he is so doped up he can
barely walk and talk.”
THINK CRITICALLY
1. What should the nurse’s response be to the information Mrs.
O’Day has shared?
2. Describe the risks to Mr. O’Day in his current approach to pain

management.
3. Describe the possible reasons Mr. O’Day has chosen the

approach to pain management that he has.
4. What plan could be developed to provide a safer pain

management strategy for Mr. O’Day?
Comforting
Heavy assignments, fast-paced schedules, and pressures to complete tasks
are common experiences for nurses in today’s health care system. In the
midst of all the doing that is demanded, the significance of being with
patients can be minimized. However, comforting and healing occur through
the time spent being with patients.
Granted, the quantity of time nurses have available to spend with
patients is limited, but the quality of that time is significant to comforting
and healing (Fig. 13-1). Quality time with patients that fosters comforting is
reflected by the following:
FIGURE 13-1 The quality of time nurses spend with
patients is significant to comforting and healing. Spending
quality time involves giving patients undivided attention,
regardless of the length of the interaction.
Giving the patient undivided attention regardless of the length of the

interaction. One method for achieving this is to pause before coming
in contact with the patient, take a deep breath, and mentally affirm that
you are going to focus on the patient during the time you are together.
Sometimes, it is helpful to visualize a basket that you are leaving the
burdens and tasks of the day in as you enter the patient’s room or
home.
Listening attentively. Encourage the patient to speak and demonstrate
interest through body language and feedback. Feeling that he or she is
not heard adds to the patient’s discomfort.
Explaining. Describe procedures, changes, and progress. Do not
assume that a patient understands a routine procedure.
Touching. Gently rubbing the patient’s shoulders, massaging the feet,
or holding a hand offers a caring, comforting connection.
Perceiving. Watch for signs that could indicate distress, such as
sighing, tear-filled eyes, and flat affect. Validate your observations and
inquire about their cause (e.g., “Mrs. Haines, you seem a little
distracted today. Is there something you’d like to talk about?”). As
tempting as it may be to ignore a problem that is not verbalized, this
would not be a healing approach.
POINT TO PONDER
Have you ever been tempted to ignore a problem that you suspect but
that the person hasn’t verbalized? What were your motives for doing
this?
Assuring patients’ comfort is a dynamic process (Fig. 13-2) that

requires reevaluation and readjustment as needs and status change. It
requires sensitivity by nurses to patients’ cues of distress and a commitment
to alleviate suffering. It affords an opportunity for nurses to demonstrate the
healing art of their profession.
FIGURE 13-2 Pain and comforting cycle.

Adapting to Chronic Pain: A Focused

Ethnography of Black Older Adults
Source: Robinson-Lane, S. G. (2019). Geriatric Nursing. Retrieved January
29, 2020 from https://doi.org/10.1016/j.gerinurse.2019.08.001 .
Black older adults are likely to have more health problems and worse
health and functional outcomes than do White older adults, causing this
population to have a high prevalence of pain. Because pain management
tends to be poor for many Black older adults, nurses must understand
effective pain management strategies for this group to enable provision of
good care and promotion of a high quality of life. This study examined pain
management strategies used by a population of low-income, community-
based Black older adults to identify effective coping mechanisms and
improve quality of life and care outcomes.
This study used the Roy Adaptation Model, which views people as
holistic adaptive systems that are in regular interaction with their
environments. From this perspective, pain is viewed as a stimulus that
causes a response that must be adapted to in order for the person to
function. The research technique of ethnography was used to evaluate the
acts of people within specific populations to gain an understanding of their
meaning within that culture. Over a 10-month period, researchers conducted
observations, surveys, and interviews with Black/African American
residents aged 55 and older who lived in a public housing facility.
Questions were asked about pain, how it affects their health, how they
manage it, and with whom and how they talk about it.
One of the main themes to emerge from the study was the need of
people with pain to continue to have a positive outlook despite their pain
and problems. Participants in the study expressed an understanding that
although some things in life, such as pain, cannot be fully controlled, how
one responds to those things can be controlled. The second theme was the
participants’ determination that although pain might slow them down, it
would not stop them. They viewed movement as a means to stay active and
independent. Engagement with their community was important, as were
faith and prayer. Participants felt they should not talk about their pain or
complaints with family and friends but rather keep such issues to
themselves. When participants mentioned health care professionals from
whom they sought assistance for pain management, they usually identified
physicians, not nurses.
This study showed that people find many effective ways for living with
pain. It also revealed that nurses need to have a more visible and vocal role
in care. Nurses should consider discussing with patients
nonpharmacological means to manage pain and enjoy a good quality of life.
Nurses can review with patients factors that enhance their ability to live
effectively with pain, such as remaining active, engaging with their
community, interacting with family and friends, and maintaining their faith.
Nurses should strive to understand the unique background of each patient so
that culturally responsive pain management interventions can be suggested
and planned.
PRACTICE REALITIES
Eighty-two-year-old Mr. Petro lives in the community with his wife who
has dementia. He is very dedicated to his wife and does an outstanding job
caring for her and managing the household.
You are aware that Mr. Petro has osteoarthritis and have noticed that he
grimaces and displays other signs of pain when he moves. When asked
about his symptoms, he admits to having significant pain and says he isn’t
using any medications as he needs to be alert for his wife. “If it’s a choice
between being too zonked out on drugs and being mentally and physically
sharp,” he comments, “I need to go with being sharp.” He shows
prescriptions for analgesics that he hasn’t filled and seems adamant about
not using medications.
What could be done to help Mr. Petro address his need for pain
management?
1. How does society reinforce symptomatic treatment of pain rather than
correction of the underlying problem?
2. Develop an integrative care plan for the management of an older adult
who experiences chronic arthritis pain.
3. Why could prayer offer relief to someone who is suffering physically
and emotionally?
4. Describe possible reasons that reimbursement is provided for medical
procedures for pain relief rather than for comforting strategies that
nurses could provide.

questions.
A 60-year-old female client presents to the Urgent Care Center

reporting abdominal pain.
Nurse’s Notes
1100: The client is grimacing, crying, moaning, clutching her fists tightly
in pain, and shifting her position as she sits in the waiting room. When
the nurse asks where the pain is located, the client points to the upper
right portion of her abdomen, describing the pain as deep, clamping,
pressing, and aching. The nurse examines the client’s abdomen for any
discoloration, swelling, and trigger point. As the nurse palpates the upper
right portion of the client’s abdomen, the nurse notes the sensitivity to
touch and restricted movement to the upper right portion of her
abdomen, and the client quickly pushes the nurse’s hand away. The nurse
notes no discoloration to the upper abdomen but observes that the site is
swollen, with tenderness upon palpation.
When the nurse asks the client when the pain started, the client says that
a sudden and rapidly intensifying pain in the upper right portion of her
abdomen started last night. She says she has never had this kind of pain
before and has not taken any medication for the pain. The only
medication the client currently takes is atorvastatin (Lipitor) 40 mg by
mouth at night for her high cholesterol level.
Chapter Summary
The prevalence of chronic conditions increases with age, and many of these
conditions have pain associated with them. The relationship between aging
and pain perception is not fully understood, although there is evidence of an
increased threshold and decreased tolerance for pain with advancing age.
The different types of pain include nociceptive (originating from
somatic and visceral structures) and neuropathic (arising from problems
affecting the central or peripheral nervous systems). Pain can also be
described by its onset and duration; acute pain has a sudden onset and is of
short duration, and persistent or chronic pain has a gradual onset and lasts
more than 3 months.
The nurse’s pain assessment includes a review of the medical history,
general observations, interview, and physical examination. A variety of
standardized pain assessment instruments are available, such as the numeric
rating scale, visual analog scale (VAS), and McGill Pain Questionnaire.
Due to the problems that often arise from medications use in older
adults, nonpharmacologic approaches to pain management should be
considered, including dietary modifications and comfort measures. An
integrative approach, in which the most appropriate therapies from both
conventional and alternative and complementary medicine are used, is
beneficial. Many of the complementary therapies can be offered by nurses.
Online Resources
American Academy of Pain Medicine
http://www.painmed.org
American Chronic Pain Association
http://www.theacpa.org
American Massage Therapy Association
www.amtamassage.org
City of Hope Pain and Palliative Care Resource Center
http://prc.coh.org
Geriatric Pain
http://www.geriatricpain.org
Healing Touch International, Inc.
www.healingtouch.net
www.nccih.nih.gov
Therapeutic Touch International Association
www.therapeutictouch.org
References
Aging in Place. (2020). How the opioid crisis affects the elderly. AgingInPlace. Retrieved January
29, 2020 from https://www.aginginplace.org/how-the-opioid-crisis-affects-the-elderly/
2019 American Geriatrics Society Beers Criteria Update Expert Panel. (2019). American Geriatrics
Society 2019 updated AGS beers criteria for potentially inappropriate medication use in older
adults. Journal of the American Geriatrics Society , 67 , 674–694. Retrieved January 29, 2020
from https://doi.org/10.1111/jgs.15767
El Tumi, H., Johnson, M. I., Dantas, P. B. F., Maynard, M. J., & Tashani, O. A. (2017). Age-related
changes in pain sensitivity in healthy humans: A systematic review with meta-analysis.
European Journal of Pain , 21 (6), 955–964.
Hulla, R., Vanzzini, N., Salas, E., Beyers, K., Garner, T., & Gatchel, R. J. (2019). Pain management
and the elderly. Practical pain management. Retrieved January 29, 2020 from
https://www.practicalpainmanagement.com/treatments/pain-management-elderly
CHAPTER 14
Safety
Chapter Outline
Aging and Risks to Safety
Importance of the Environment to Health and Wellness
Impact of Aging on Environmental Safety and Function
Lighting
Temperature
Colors
Scents
Floor Coverings
Furniture
Sensory Stimulation
Noise Control
Bathroom Hazards
Fire Hazards
The Problem of Falls
Interventions to Reduce Intrinsic Risks to Safety
Addressing Risks Associated With Sensory Deficits
Addressing Risks Associated With Mobility Limitations
Avoiding Crime
Addressing Risks Associated With Functional Impairment
LEARNING OBJECTIVES
1. Describe the effects of aging on safety.

2. Discuss the significance of the environment to physical and
psychological health and well-being.
3. List the impact of age-related changes on the function and safety of the
environment.
4. Describe adjustments that can be made to the environment to promote
safety and function of older persons.
5. Identify bathroom hazards and ways to minimize them.
6. Discuss the effect of the environment on psychosocial health.
7. List factors that contribute to falls in older adults.
8. List measures to reduce older persons’ intrinsic risks to safety and
well-being.
9. Discuss unique safety risks of individuals with functional impairments.
TERMS TO KNOW
Injuryan act that results in harm
Macroenvironmentelements in the larger world that affect groups of
people or entire populations
Microenvironmentthe immediate surroundings with which a person
closely interacts
Restraintanything that restricts movement, can be physical or chemical
Throughout life, human beings confront threats to their lives and well-
being, such as acts of nature, pollutants, communicable diseases, accidents,
and crime. Normally, adults take preventive action to avoid these hazards
and, should they occur, attempt to control them to minimize their impact.
Older persons face the same hazards as any adult, but their risks are
compounded by age-related factors that reduce their capacity to protect
themselves from and increase their vulnerability to safety hazards.
Gerontological nurses need to identify safety risks when assessing older
adults and provide interventions to address existing and potential threats to
safety, life, and well-being.
AGING AND RISKS TO SAFETY

Accidents rank as the seventh leading cause of death for older adults, with
unintentional falls being the leading type of injury treated in hospital
emergency departments (Centers for Disease Control and Prevention,
2019a). In addition, falls are the leading cause of premature
institutionalization and long-term disability for older adults (Bolton, 2019).
Age-related changes, altered antigen–antibody response, and the high
prevalence of chronic disease cause older persons to be highly susceptible
to infections. Pneumonia and influenza rank as the eighth leading cause of
death in this age group, and pneumonia is the leading cause of infection-
related death. Older adults have a threefold greater incidence of nosocomial
pneumonia as compared with younger age groups; older adults experience
gastroenteritis caused by Salmonella species more frequently than do
persons younger than 65 years of age; and urinary tract infections increase
in prevalence with age. Older adults account for more than half of all
reported cases of tetanus, endocarditis, cholelithiasis, and diverticulitis.
Atypical symptomatology often results in delayed diagnosis of infection,
contributing to older adults’ higher mortality rate from infections; for
instance, older persons are more likely to die from appendicitis than
younger persons due to the altered presentation of symptoms delaying
diagnosis.
Altered pharmacokinetics, self-administration problems, and the high
volume of drugs consumed by older individuals can also lead to
considerable risks to safety. Risks include adverse effects and accidents
resulting from effects such as drowsiness or dizziness. It is estimated that
15% of geriatric admissions to hospitals are associated with drug-related
problems (Ayalew, Tegegn, & Abdela, 2019).
Table 14-1 lists the various age-related factors that can pose risks to the
safety and well-being of older adults and potential nursing problems
associated with these risks.
TABLE 14-1 Aging and Risks to Safety
IMPORTANCE OF THE
ENVIRONMENT TO HEALTH AND
WELLNESS
The environment can be considered as consisting of two parts, the
microenvironment and the macroenvironment . The microenvironment
refers to our immediate surroundings with which we closely interact (e.g.,
furnishings, wall coverings, lighting, room temperature, and room sounds).
The macroenvironment consists of the elements in the larger world that
affect groups of people or even entire populations (e.g., the weather,
pollution, traffic, and natural resources). Because the microenvironment can
be more easily manipulated and realizes more immediate benefits, it is the
focus of this discussion.
Ideally, the environment provides more than shelter; it should promote
continued development, stimulation, and satisfaction to enhance our
psychological well-being. This is particularly important for older adults,
many of whom spend considerable time in their homes or in a bedroom of a
facility. To achieve the fullest satisfaction from their microenvironments,
older adults must have various levels of needs met within their
surroundings. This can be exemplified by comparing environmental needs
with the basic human needs postulated by Maslow (Table 14-2). Similar to
Maslow’s theory, it can be hypothesized that higher level satisfaction from
the environment cannot be achieved unless lower level needs are fulfilled.
This may explain why some older individuals have the following priorities
and problems:
TABLE 14-2 Environmental Needs Based on Maslow’s

Hierarchy
They do not think installing a free smoke detector is important when
there are rodents in their apartment.
They refuse to have their house remodeled because it will make them
look too affluent in a high-crime neighborhood and be a target for
burglary.
They remain socially isolated rather than invite guests to a house
perceived as shabby.
They are unwilling to engage in creative arts and crafts if they are
adjusting to a new and unfamiliar residence.
Nurses must be realistic in their assessment of the environment to

determine which levels of needs are being addressed and to plan measures
to promote the fulfillment of higher level needs.
POINT TO PONDER
What aspects of your home environment contribute to the fulfillment of
the higher level needs based on Maslow’s hierarchy?
IMPACT OF AGING ON
ENVIRONMENTAL SAFETY AND
FUNCTION
Previous chapters have described some of the changes experienced with
aging. These, along with limitations imposed by highly prevalent chronic
diseases, create special environmental problems for older people, such as
those listed in Table 14-3.
TABLE 14-3 Potential Environmental Impact of Various

Physical Limitations
Of course, specific disabilities accompany various diseases and create
unique environmental problems, as is witnessed with a person who is
cognitively impaired.
Based on common limitations found among older people, most older
adults need an environment that is safe, functional, comfortable, personal,
and normalizing and that compensates for their limitations. Creating such
an environment requires considering lighting, temperature, colors, scents,
floor coverings, furniture, sensory stimulation, noise control, bathroom
hazards, and psychosocial factors. Box 14-1 provides a checklist for
assessing basic standards for the older adult’s environment.
BOX 14-1 Environmental Assessment Checklist

Lighting
Light has a more profound effect than simply illuminating an area for better
visibility. For example, light affects the following:
Function. An individual may be more mobile and participate in more

activities in a brightly lit area, whereas a person in a dim room may be
more sedate.
Orientation. An individual may lose the perspective of time in a room
that is constantly lit or darkened for long periods. For example,
persons exposed to the bright lighting in intensive care units for
several days often cannot determine if it is day or night. A person who
awakens in a pitch-dark room may be disoriented for a few seconds.
Mood and behavior. Blinking psychedelic lights cause a different
reaction from candlelight. In restaurants, customers are quieter and eat
more slowly with soft, low illumination levels than with harsh, high
ones.
Several diffuse lighting sources rather than a few bright ones are best in
areas used by older adults. Fluorescent lights are the most bothersome
because of eye strain and glare. The use of fluorescent lighting for
economic reasons actually may not be cost-effective; although less
expensive to operate, they have higher maintenance costs. Sunlight can be
filtered by sheer curtains. The nurse should assess the environment for
glare, paying particular attention to light bouncing off shining floors and
furniture. Evaluate lighting from a seated position because insufficient
lighting, shadows, glare, and other problems can appear differently from
chair or bed level than from a standing position.
Nightlights help facilitate orientation during the night and provide
visibility to locate light switches or lamps for nighttime mobility. A soft red
light can be useful at night in the bedroom to improve night vision.
Exposure to natural light during the normal 24-hour dark–light cycle
helps to maintain body rhythms, which, in turn, influence body temperature,
sleep cycles, hormone production, and other functions. When the sleep–
wake cycle is interrupted, the body’s internal rhythms can be disrupted.
This factor warrants consideration in hospital and nursing home settings,
where areas may be lit around the clock to facilitate staff activities;
darkening areas at night can assist in maintaining normal body rhythms.
Nurses should also consider the lack of exposure to natural sunlight often
experienced by institutionalized or homebound ill older individuals.
Consideration should be given to taking these individuals outdoors, when
possible, and opening windows to allow natural sunlight to enter.
Temperature
It has been known from Galen’s time in 160 ad that hot and cold
temperatures affect the performance of human beings. Tactile sensitivity,
vigilance performance, and psychomotor tasks become impaired in
temperatures below 55°F (13°C).
Because older adults have lower normal body temperatures and
decreased amounts of natural insulation, they are especially sensitive to
lower temperatures (Fig. 14-1); thus, maintaining adequate environmental
temperature is significant. The recommended room temperature for an older
person should not be lower than 75°F (24°C). The older the person is, the
narrower the range of temperatures tolerated without adverse reactions.
Room temperatures less than 70°F (21°C) can lead to hypothermia in older
adults.
FIGURE 14-1 Because older adults are especially
sensitive to lower temperatures, controlling the
environmental temperature is important. Additional layers
of clothing may also be needed.
Although not as significant a problem as hypothermia, hyperthermia

can also create difficulty for older persons, who are more susceptible to its
ill effects than younger adults. Brain damage can result from temperatures
exceeding 106°F (41°C). Even in geographic areas that do not experience
excessively high temperatures, consideration must be given to the
temperature of rooms or homes in which doors and windows are not opened
and no air conditioning is present. Persons with diabetes or cerebral
atherosclerosis are at high risk for becoming hyperthermic.
Colors
There is much debate concerning the best environmental color scheme for
older people. Colors such as red, yellow, and white can be stimulating and
increase pulse, blood pressure, and appetite, whereas blue, brown, and earth
tones can be relaxing. Orange can stimulate appetite, whereas violet has the
opposite effect. Green is considered the master healer color and gives a
sense of well-being. Black and gray can be depressing. Although certain
colors are associated with certain effects, experiences with colors play a
significant part in individual reactions to and meanings inferred from
various colors. Because individual response can vary, it may be best to
focus on the use of colors to enhance function and, whenever possible, on
the personal preference of the room’s resident. Contrasting colors are
helpful in defining doors, stairs, and level changes within an area. When the
desire is to not draw attention to an area (e.g., a storage closet), walls
should be a similar color or within the same color family. Certain colors
may be used to define different areas; for example, bedrooms may be blue
and green, eating and activity areas orange and red, and lounge areas gray
and beige.
Patterned wall and floor coverings can add appeal to the environment;
however, wavy patterns and diagonal lines can cause a sensation of
dizziness and could worsen the confusion of persons with cognitive
impairments. Using a simple pattern or a mural on one wall of the room can
be effective and pleasing.
Scents
Scents have been used for aesthetic and medicinal purposes from the
earliest of times. Although the use of perfumes and colognes is hardly new,
the therapeutic use of scents, aromatherapy (or phytomedicine), has become
popular in the United States only recently. However, it is a commonly used
extension of orthodox medicine in countries such as Germany and France.
Involving more than just the smelling of pleasant fragrances,
aromatherapy is the therapeutic use of essential oils. Essential oils are
highly volatile droplets made by plants and stored in their veins, glands, or
sacs; when they are released (by crushing or breaking open the plant), the
aroma is released along with them. When the chemicals within the essential
oils are inhaled, they are carried to the olfactory bulb, stimulating nerve
impulses that travel to the limbic system of the brain for processing. An
organ called the amygdala is housed in the limbic system and stores
memories associated with different scents. In some cases, the memories can
be dormant for many years.
Essential oils can also be absorbed through the skin through baths,
compresses, or rubbing or massaging them onto the skin surface. Like
topical medications, these oils are absorbed and produce physiologic
effects.
Floor Coverings
Carpeting is an effective sound absorber, and for most people, it represents
warmth, comfort, and a homelike atmosphere. There even has been
speculation that the use of carpeting in institutional settings can reduce the
number of fractures associated with falls. However, carpeting does create
problems, which include the following:
Static electricity and cling. Many older persons have a shuffling gait
and incomplete toe lift during ambulation; this can produce
uncomfortable static electricity, and the clinging of slippers and shoe
soles to the carpeting could cause falls.
Difficult wheelchair mobility. The more plush the carpet is, the more
difficult it becomes to roll wheels on its surface.
Cleaning. Spills are more difficult to clean on a carpeted surface; even
with washable surfaces, discoloration can result.
Odors. Cigarette smoke and other odors can cling to carpeting,
creating unpleasant odors that last. Urine, vomitus, and other
substances demand special deodorizing efforts that may not prove
effective.
Pests. The undersurface of carpeting provides a wonderful
environment in which cockroaches, moths, fleas, and other pests can
reside.
To derive some of the benefits of carpeting, carpeting may be applied to

some of the wall surface rather than the floor. This can provide a noise
buffer, textural variation, and a decor with fewer housekeeping and
maintenance problems than floor carpeting.
Scattered and area rugs provide an ideal source for falls and should not
be used. Tiled floor covering should be laid on a wood foundation rather
than directly on a cement surface for better insulation and cushion. Bold
designs can cause dizziness and confusion in ambulation; a single solid
color is preferable. A nonglare surface is essential for older adults. Floor
treatments that create a nonslip surface are particularly useful in bathrooms,
kitchens, and areas leading from outside doors.
Furniture
Furnishings should be appealing, functional, and comfortable. A firm chair
with arm rests provides support and assistance in rising from or lowering
into the seat; low, sinking cushions are difficult for older people to use.
Chairs should also be of an appropriate height to allow the individual’s feet
to rest flat on the floor with no pressure behind the knees. Rockers provide
relaxation and some exercise to older people. Love seats are preferable to
larger sofas because no one risks being seated in the center without arm
rests for assistance.
Upholstery for all furniture should be easy to clean, so leather and vinyl
coverings are more useful than cloth. Upholstery should be fire resistant,
with a firm surface without buttons or seams in areas that come in contact
with the body. Rather than the back, seat, and arm rest being one connecting
unit, open space where these sections meet allows for ventilation and easier
cleaning. Recliners can promote relaxation and provide a means for leg
elevation, but they should not require strenuous effort to change positions.
Tables, bookcases, and other furniture should be sturdy and able to
withstand weight from persons leaning for support. If table lamps are used,
bolting them to the table surface can prevent their being knocked over in an
attempt to locate them in the dark. Foot stools, candlestick tables, plant
stands, and other small pieces of furniture would be best placed in low-
traveled areas, if they are present at all. Furniture and clutter should not
obstruct the path from the bedroom to the bathroom.
Drawers should be checked for ease of use. Sanding and waxing the
corners and slides can facilitate their movement. In hanging mirrors, the
height and function of the user must be considered; obviously, persons
confined to wheelchairs will need a lower level than their ambulatory
counterparts.
Individuals with cognitive impairments need a particularly simple
environment. Furniture should look like furniture and not pieces of
sculpture. The use of furniture should be clear. Placement of a commode
chair next to a sitting chair can be confusing and result in the improper use
of both.
Sensory Stimulation
By making thoughtful choices and capitalizing on the objects and activities
of daily life, much can be done to create an environment that is pleasing and
stimulating to the senses. Some suggestions are as follows:
Textured wall surfaces

Soft blankets and spreads
Differently shaped and textured objects to hold (e.g., a round
sheepskin-covered throw pillow and a square tweed-covered one)
Murals, pictures, sculptures, and wall hangings
Plants and freshly cut flowers
Coffee brewing, food cooking, perfumes, and oils
Birds to listen to and animals to pet
Soft music
Different areas in the person’s living space can be created for different
sensory experiences. The appetite of nursing home residents could be much
improved if, within their own dining area, they could smell the aroma of
their coffee brewing or bread toasting rather than just having the finished
product placed on a tray before them.
For bed-bound persons or those with limited opportunity for sensory
stimulation, special efforts are necessary. In addition to the suggestions
given, one could regularly change the wall hangings in their rooms. Many
libraries and museums will loan artwork free of charge. Collaboration with
a local school can yield unique art for the older person and meaningful art
projects for the students. A “sensory stimulation box” that contains objects
of different textures, shapes, colors, and fragrances could provide an
activity.
Noise Control
Sound produces a variety of physiologic and emotional effects. Many of the
sounds we take for granted—television, traffic noise, conversation from an
adjoining room, appliance motors, leaking faucets, and paging systems—
can create difficulties for the older person. Many older adults already
experience some hearing limitation as a result of presbycusis and need to be
especially attentive to compensate for this deficit.
Environmental sounds compete with the sounds that older adults want
or need to hear, such as a telephone conversation or the evening news,
resulting in poor hearing and frustration. Unwanted, disharmonic, or
chronic noise can be a stressor and cause physical and emotional symptoms.
Ideally, noise control begins with the design of the building. Careful
landscaping and walls can buffer outdoor noise. Acoustical ceilings, drapes,
and carpeting—also useful on walls—are helpful, as is attention to
appliance and equipment maintenance. Radios and televisions should not be
playing when no one is listening; if one person needs a louder volume,
earphones for that individual can prevent others from being exposed to high
volumes. In institutional settings, individual pocket pagers are less
disruptive than intercoms and paging systems.
Bathroom Hazards
Many accidental injuries occur in the bathroom and can be avoided with
common sense and inexpensive measures. Particular attention should be
paid to the following aspects:
Lighting. A small light should be on in the bathroom at all times.

Because urinary frequency and nocturia are common, older adults use
the bathroom often and can benefit from the increased visibility.
Constant lighting is especially helpful if the switch is located outside
the bathroom, so that the individual does not have to enter a dark area
and then search for a switch.
Floor surface. Towels, hair dryers, and other items should not be left
on the bathroom floor, and throw rugs should not be used. For older
people, falls are dangerous under any circumstance, but the high
likelihood of falling and striking one’s head on the hard surface of a
tub or toilet increases the potential seriousness of the fall. Leaks
should be corrected to avoid creating slippery floors, which are another
cause of falls.
Faucets. Lever-shaped faucet handles are easier to use than round ones
or those that must have pressure exerted on them. Older people can
risk falling or burning themselves by releasing too much hot water as
they struggle to turn a faucet handle. This problem supports the need to
control hot water temperature centrally. Color coding the faucet
handles makes differentiation of hot and cold easier than small letters
alone.
Tubs and shower stalls. Nonslip surfaces are essential for tubs and
shower floors. Grab bars on the wall and safety rails attached to the
side of the tub offer support during transfers and a source of
stabilization when bathing (Fig. 14-2). A shower or bath seat offers a
place to sit when showering and, for tub bathers, a resting point when
lifting to transfer out of the tub. Because a drop in blood pressure may
follow bathing, it may be beneficial to have a seat alongside the tub to
enable the bather to rest when drying.
Toilets. Grab bars or support frames aid in the difficult task of sitting
down and rising from a toilet seat. Because the low height of toilet
seats makes them difficult for many older people to use, a raised seat
attachment could prove useful.
Electrical appliances. The use of electric heaters, hair dryers, and
radios in the bathroom produces a considerable safety risk. Even
healthy, agile persons can accidentally slip and pull an electrical
appliance into the tub with them.
FIGURE 14-2 Safety features in this shower include grab

bars, safety rails, shower seat, and transfer seat.
Medical supply stores and health care equipment suppliers offer a

variety of devices that can make the bathroom and other living areas safer
and more functional. Sometimes, less expensive replicas can be homemade
and be equally effective. It is much wiser to invest in and use these assistive
devices to prevent an injury than to wait until an injury occurs.
Fire Hazards
Older adults have a risk of burn injuries as a result of common hazards in
the home. Approximately 80% of fire deaths in the United States occur in
the home, with older adults having a 2.5 times greater risk of dying in a fire
than the population as a whole (U.S. Fire Administration, 2019). Kitchen
fires often result when unattended pots with boiling liquids become dry,
because the person has forgotten them. Older individuals can aid in
preventing these fires by staying in the kitchen while cooking, setting a
timer to remind them to check the pot, or using a microwave to heat liquids.
Careless disposal of matches or cigarette butts, falling asleep holding a
cigarette, and clothing or linens catching fire while a cigarette is being lit
are potential risks to older smokers. Older smokers need to be cautioned
about these risks. Restricting smoking to specific locations and times of the
day can aid in reducing the risks.
For those older adults who rely on space heaters, inspection of the
heater is beneficial in assuring its safety. Space heaters should have an
automatic shutoff mechanism to prevent fire if the heater is knocked over or
falls and intact electrical cords. They should be used with an appropriate
electrical outlet (i.e., one that is not overloaded).
Fireplaces may provide warmth and a cozy atmosphere, but they can
also cause fires. Wood-burning fireplaces need cleaning to prevent chimney
blockage; this may be a difficult task for older adults. Without proper
cleaning, fire and smoke cannot be adequately vented and can result in
smoke inhalation and fire. When a fireplace is present in the home,
questions about its use and care should be asked.
Physical objects form only a partial picture of the environment. The human
elements make the picture complete. Feelings and behavior influence and
are influenced by the individual’s surroundings.
From the homeless woman who claims the same department store
alcove as her resting place each night to the nursing home resident who
forbids anyone to open her bedside cabinet, most people want a space to
define as their own. This territoriality is natural and common; many of us
would become uncomfortable with a visitor to our office sifting through the
papers on our desk, a house guest looking through our closets, or a stranger
snuggling close to us on a subway when the rest of the seats are empty. The
annoyance we feel at having someone looking into our window, peering
over a privacy fence into our yard, playing music loudly enough to be heard
in our home, or staring at us demonstrates that our personal space and
privacy can be invaded without direct physical contact.
To the dependent, ill, older person, privacy and personal space are no
less important, but they may be more difficult to achieve. In an institutional
setting, staff and other patients may make uninvited contact with a person’s
territory and self at any time, ranging from the confused resident who
wanders into others’ rooms to staff members who lift blankets to check if
the bed is dry. Even in the home, well-intentioned relatives may not think
twice about discarding or moving personal possessions in the name of
housekeeping or entering a bathroom unannounced just to ensure that all is
well. The more dependent and ill individuals are, the more personal space
and privacy may be invaded. Unfortunately, for these individuals who have
experienced multiple losses and a shrinking social world, the regulation of
privacy and personal space may be one of the few controls they can
exercise. It is important that caregivers realize and respect this need through
several basic measures:
Define specific areas and possessions that are the individual’s (e.g.,
this side of the room; this room in the house; this chair, bed, or closet).
Provide privacy areas for periods of solitude. If a private room is not
available, arrange furniture to achieve maximum privacy (e.g., beds on
different sides of the room facing different directions, use of
bookshelves and plants as room dividers).
Request permission to enter personal space. Imagine an invisible circle
of about 5 to 10 ft around the person and ask before coming into it:
“May I sit your new roommate next to you?” “Is it all right to come
in?” “May I clean the inside of your closet?”
Allow maximum control over one’s space.
Components of the environment can facilitate or discourage mental and

social activity. Clocks, calendars, and newspapers promote orientation and
knowledge of current events. Easily accessible books and magazines
challenge the mind and expand horizons. Games and hobbies can offer
stimulation and an alternative to watching television. The placement of
chairs in clusters or in busy but not heavily trafficked areas is conducive to
interaction and involvement with a larger world.
Although fewer than 5% of older adults reside in nursing homes,
approximately 25% of older persons will spend some time in such a facility
during their last years of life. Nursing homes are not reflections of normal
homelike environments; adjustment to them can be difficult. Familiar
surroundings are replaced with new and strange sights, sounds, odors, and
people. Cues that triggered memory and function are gone, and new ones
must be mastered at a time when reserves are low. Relatives and neighbors
who gave love and understanding are replaced with people who know only
that person before them now and who have many tasks to be done. The
individual who is experiencing this may have a variety of reactions, such as
the following:
Depression over the loss of health, personal possessions, and

independence
Regression because of the inability to manage the stress at hand
Humiliation by having to request basic necessities and minor desires,
such as toileting, a cup of tea, or a cigarette
Anger at the loss of control and freedom
Nursing homes cannot offer the same satisfaction as the person’s own
home, but the institutional environment can be enhanced through the
following:
An attractive decor
Inclusion of the individual’s personal possessions
Respect for privacy and personal territory
Recognition of the individuality of the resident
Allowance of maximum control over activities and decision making
Environmental modifications to compensate for deficits
The human environment will be more important to the nursing home

resident than the physical surroundings. Superior interior decoration and
lovely color schemes mean little when respect, individuality, and sensitivity
are absent.
THE PROBLEM OF FALLS

One of the significant concerns about safety in later life relates to the
incidence of falls. Each year 25% of persons aged 65 years and older
experience a fall, with one in five of those falls resulting in serious injury;
falls are the leading cause of fatal and nonfatal injuries in the older
population (Centers for Disease Control and Prevention [CDC], 2019b).
Even if no physical injury occurs, fall victims may develop a fear of falling
again (i.e., postfall syndrome) and reduce their activities as a result; this can
lead to unnecessary dependency, loss of function, decreased socialization,
and a poor quality of life.

Many factors contribute to the high incidence of falls in older adults (Box
14-2). Common risk factors include the following:
BOX 14-2 Risk Factors for Falls

AGE-RELATED FACTORS
History of falls
Female aged 75 years and older
Impaired vision
Gait disturbance
Postural hypotension
HEALTH CONDITIONS OR FUNCTIONAL

IMPAIRMENTS
Physical disability
Incontinence, nocturia
Delirium, dementia
Mood disturbance
Hoarding disorder
Dizziness
Weakness
Fatigue
Ataxia
Paralysis
Edema
Use of cane, walker, wheelchair, crutch, or brace
Use of restraint
Presence of IV, indwelling catheter
Unstable cardiac condition
Neurologic disease
Parkinsonism
Transient ischemic attack
Cerebrovascular accident
Diabetes mellitus
Peripheral vascular disease
Orthopedic disease
Foot problems
Multiple diagnoses
MEDICATIONS
Anticholinergics
Antidepressants
Antihypertensives
Antipsychotics
Barbiturates
Benzodiazepines
Diuretics
Sedatives
Tranquilizers
Multiple medications
ENVIRONMENTAL FACTORS
Newly admitted to hospital/nursing home
Unfamiliar environment
Highly polished floors
Inadequate environmental lighting
Absence of railings and grab bars
Poor environmental design
Clutter, equipment
Age-related changes: reduced visual capacity; problems differentiating

shades of the same color, particularly blues, greens, and violets;
cataracts; poor vision at night and in dimly lit areas; less foot and toe
lift during stepping; altered center of gravity leading to balance being
lost more easily; slower responses; urinary frequency
Improper use of mobility aids: using canes, walkers, and wheelchairs
without being prescribed, properly fitted, or instructed in safe use; not
using brakes during transfers
Medications: particularly those that can cause dizziness, drowsiness,
orthostatic hypotension, and incontinence, such as antihypertensives,
sedatives, antipsychotics, and diuretics
Unsafe clothing: poor-fitting shoes and socks, long robes or pants legs
Disease-related symptoms: postural hypotension, incontinence,
reduced cerebral blood flow, edema, dizziness, weakness, fatigue,
brittle bones, paralysis, ataxia, mood disturbances, confusion
Environmental hazards: wet surfaces, waxed floors, objects on floor,
poor lighting, clutter produced by hoarding
Distractions: looking at cellphone screen while walking, gazing into
distance rather than observing immediate ground surface
Caregiver-related factors: improper use of restraints and bedrails,
delays in responding to requests, unsafe practices, poor supervision of
problem behaviors
A history of falls can predict an individual’s risk of future falls;

therefore, nurses should carefully assess persons who have experienced a
fall or even a minor stumble to identify factors that may increase their risk
of this problem. Interventions should be planned accordingly.
Caution is needed to address the risk of falls associated with postural
hypotension. This is a common problem that causes dizziness when older
adults first stand after awakening. On awakening, older adults should spend
several minutes resting in bed and stretching their muscles, followed by
several more minutes of sitting on the side of the bed before rising to a
standing position. The orthostatic effect of rising to a standing position after
bathing, coupled with the dilation of peripheral vessels from the warm bath
water, also leads to fainting and falls. Rubber mats or nonslip strips, a bath
seat, and resting before rising are essential measures in the bathtub.
Health care facilities can find it beneficial to have an active program to
prevent falls that incorporates some of the interventions described in
Nursing Problem Highlight 14-1, Risk of Accidents and Injuries. Regular,
careful inspection of the environment and prompt correction of
environmental hazards (e.g., leaks, cracks in walkways, and broken bed
rails) are essential (see Box 14-1). An evalua tion of risk of falling should
be incorporated into the assessment of each older client. The Hendrich II
Fall Risk Model is a short tool that aids in assessing fall risk (see Online
Resources at the end of this chapter). Staff should orient older clients to
new environments and reinforce safe practices, such as using bed rails,
braking wheelchairs and stretchers during transfers, and promptly cleaning
spills.
RISK OF ACCIDENTS AND INJURIES
Overview
Many older persons are limited in their ability to protect themselves from
hazards to their health and well-being. Indications that this problem exists
can be manifested through a history of frequent falls or accidents, the
presence of an unsafe environment, adverse drug reactions, infections,
frequent hospitalizations, and altered mood or cognition.
Age-related changes, health problems, weak or immobile state, sensory
deficits, improperly fitted or used mobility aids, unsafe use of medications,
unsafe environment, altered mood or cognitive function.
Goal
The patient is free from accidents and injuries.
Interventions
Assess risk of injury to patient (e.g., falls risk, activities of daily
living and impaired activities of daily living function, mental status,
gait, medication use, nutritional status, environment, knowledge of
injury prevention practices).
Identify patients at high risk for injury and plan measures to reduce
their specific risks.
Orient patients to new environments.
Encourage patients to wear prescribed eyeglasses, hearing aids, and
prosthetic devices.
Ensure patients use canes, walkers, and wheelchairs properly and
only when prescribed.
Avoid the use of physical or chemical restraints unless assessed to be
absolutely necessary; use proper procedures to ensure safety when
they are used.
Advise patients to change positions slowly, holding on to a stable
object as they do.
Keep floors free from litter and clutter.
Provide good lighting in all areas used by patient.
Store cleaning solutions and other poisonous substances in a safe
area.
Encourage patients to use handrails and grab bars.
Assist patients as needed with transfers.
Review medications used for continued need, effectiveness, and
appropriateness of dosage; instruct patients in safe medication use.
Be sure patients wear well-fitted, low-heeled shoes, and robes and
pants of an appropriate length.
Promptly detect and obtain treatment for changes in physical or
mental health status.
Review home environment for safety risks and assist patient in
obtaining assistance in eliminating risks (e.g., low-cost home
improvements, housekeeping aid, or senior housing).
If safety risks are associated with insufficient finances (inability to
purchase prescriptions, heating oil, or home repairs), refer patient to
social service agency to explore possibility of obtaining assistance.
KEY CONCEPT
A program to prevent falls is essential to settings that provide services to
older adults.
Some falls will occur despite the best preventive measures. Caregivers
should assess the fall victim and keep him or her immobile until a full
examination for injury is done. Skin breaks or discoloration, swelling,
bleeding, asymmetry of extremities, lengthening of a limb, and pain are
among the findings to note. Medical examination and x-rays are warranted
for even the slightest suspicion of a fracture or other serious injury.
Fractures often are not readily apparent immediately after the fall; it may be
only when the person attempts to resume normal activity that the injured
bone becomes misaligned. Also, areas other than the direct point of impact
may be injured in the fall; for instance, a person may have fallen on the
knee, but the force of the fall may have placed enough stress on the hip to
fracture the femur. Careful examination and observation can aid in the
prompt diagnosis of injury and introduction of appropriate treatment.
In addition to physical injury resulting from a fall, older adults may
experience psychological trauma. Falls can cause an older adult to feel
vulnerable and fearful of losing independence. Unnecessary restriction of
activity may result. Patients may share this information during the
assessment when asked about falls; further, possible signs could indicate a
fear of falling, such as excess caution in changing positions and ambulating,
unnecessarily restricting mobility, grabbing furniture or a wall while
walking or transferring, or apparent anxiety when ambulating. It can be
useful to offer suggestions for preventing falls (e.g., wearing safe shoes,
keeping areas well lighted, holding on to rails when climbing stairs, and
avoiding climbing ladders) while encouraging maximum activity.

Throughout most of the 20th century, restraints were widely used in health
care settings under the belief that they would prevent falls, promote
patients’ compliance with treatments, and aid in managing behavioral
symptoms. This practice was generally unchallenged until the 1990s, when
studies began to emerge suggesting that restraints contribute to serious
injuries and worsen cognitive function. Since then, the combination of
research-based clinical evidence, clinical enlightenment, advocacy groups’
efforts, and changed standards and regulations concerning restraints has
contributed to a reduction in restraint use.
CONSIDER THIS CASE

Mrs. Jensen resides in an assisted living
community. She has normal cognitive function and other than diabetes and
chronic obstructive pulmonary disease is in relatively good health.
Several weeks ago, Mrs. Jensen experienced two falls for which she
had no injuries other than bruises. She attributes one to trying to turn
around too quickly and the other to tripping on her slipper. Concerned for
her safety, Mrs. Jensen’s daughter buys a wheelchair for her mother to use.
She advises Mrs. Jensen to use the wheelchair whenever she is out of bed.
Mrs. Jensen now uses the wheelchair every time she is out of the bed.
The staff have questioned her use of it, advising her that she really doesn’t
need it. Mrs. Jensen responds, “My daughter told me to use this so I
wouldn’t hurt myself by falling when I walk. She paid a lot of money for it
and cares about me, so I’m using it.” When the staff continues to
encourage Mrs. Jensen to ambulate rather than use the wheelchair, the
daughter asks to speak to the nursing staff caring for Mrs. Jensen and
firmly advises them: “I’m not going to see my mother fall and hurt herself,
so she is going to use that wheelchair. And if you force her to walk and she
falls, you’re going to have a giant lawsuit on your hands!”
THINK CRITICALLY
1. How should the nursing staff respond to the daughter?
2. What are the risks of allowing and not allowing Mrs. Jensen to
use the wheelchair?
3. Describe the plans that could be implemented to encourage Mrs.

Jensen’s safe ambulation.
Restraints consist of anything that restricts freedom of movement. They

can consist of physical restraints, such as seat belts, vests, wrist ties, “geri-
chairs,” bilateral full-length side rails, and chemical restraints, which are
drugs given solely for the purpose of discipline or staff convenience.
Applying physical restraints to an already agitated person increases his
or her fear and worsens behavioral symptoms. This hardly reflects caring,
compassionate practice. In addition, restraints can lead to serious
complications, including aspiration, circulatory obstruction, cardiac stress,
skin tears and ulcers, anorexia, dehydration, constipation, incontinence,
fractures, and dislocations.
POINT TO PONDER
How do you think you would react if you entered a hospital or nursing
home room in which your loved one was being cared and found that
person struggling to be freed from applied restraints?
The nonuse of physical and chemical restraints is a standard that

gerontological nurses should promote in all clinical settings. A thorough
assessment is beneficial in identifying factors that contribute to agitation
and other negative behaviors; these factors could include visual deficits,
impaired hearing, unrelieved pain, delirium, dyspnea, excess sensory
stimulation, and lack of familiarity with a new environment. Addressing the
specific factor contributing to the behavior could calm the patient and
eliminate the need for restraints. When behaviors cannot be modified,
alternatives to restraints can be considered, such as the following:
Placing patient in a room near the nursing station in which close
observation and frequent contact are facilitated
One-to-one supervision and companionship (often, family members
and volunteers can provide this)
Use of electronic devices that alert staff when the patient attempts to
get out of bed or leaves a designated area
Repositioning, soothing communication, touch, and other comfort
measures
Frequent reality orientation and reassurance
Diversional activities
Close observation and documentation of patients’ responses to

restraints and alternatives to restraints are essential.
INTERVENTIONS TO REDUCE
INTRINSIC RISKS TO SAFETY
When a fall injury or other problem occurs, older adults take longer to
recover and risk significantly more complications; thus, the key word in
safety is prevention. Because of intrinsic risk factors often present in older
adults, additional preventive measures are needed beyond those practices
that promote safety for persons of any age. A variety of practical methods,
most of which are inexpensive, promote safety and should be considered in
the care of older adults. These measures not only aid in avoiding injury and
illness but also can increase self-care capacity.
KEY CONCEPT
Prevention is important because older adults require more time to
recover from injuries and suffer more complications.

Adequate fluid intake can be difficult for older adults, particularly if they
are depressed, demented, or physically incapable of maintaining good fluid
and food intake. Thirst perception declines with age, causing older persons
to be less aware of their fluid needs. Sometimes, a self-imposed fluid
restriction is a means of managing urinary frequency; in other situations,
the mental capacity to respond to the thirst sensation may be lacking. The
result is insufficient fluid intake, which causes the body’s already reduced
tissue fluid reserves to be tapped. Unless contraindicated, older adults
should ingest at least 1,500 mL of fluid each day. Many sources other than
plain water can provide this requirement, including soft drinks, coffee, tea,
juices, Jello, ices, and fresh citrus fruits.
Poor oral health, gastrointestinal symptoms, altered cognition,
depression, and dependency on others for feeding can lead to poor food
intake. Even healthy older people may have difficulty ingesting a proper
diet because of factors such as limited funds, problems in shopping for
food, and lack of motivation to prepare healthy meals. The fatigue,
weakness, dizziness, and other symptoms associated with a poor nutritional
status can predispose older adults to accidents and illness. An appropriate
quality and quantity of food intake can increase the body’s resistance to
such problems. See Chapter 11 for more specific information about
hydration and nutritional needs.
Addressing Risks Associated With Sensory

Deficits
Changes in vision that occur with aging can pose threats to safety. Most
people older than 40 years require corrective lenses for vision. The visual
capacity of older adults can change frequently enough that regular
evaluation of vision and the effectiveness of prescribed lenses is warranted.
Annual eye examinations are helpful not only in ensuring the
appropriateness of corrective lenses but also in detecting, in a timely
fashion, the many eye disorders that increase in prevalence with age.
To compensate for reduced peripheral vision, affected individuals
should be approached from the front rather than from the back or side, and
furniture and frequently used items should be arranged in full view. Altered
depth perception may hamper the ability of the aged to detect changes in
levels; this may be alleviated by providing good lighting, eliminating clutter
on stairways, using contrasting colors on stairs, and providing signals to
indicate when a change in level is being approached. The filtering of low-
tone colors is an important consideration when decorating areas for older
adults; bright reds, oranges, and yellows and contrasting colors on doors
and windows can be appealing and helpful. Difficulty in differentiating
between low-tone colors should be considered if urine testing is being
taught to older diabetics because these tests often require color
differentiation. Cleaning solutions, medications, and other materials should
be labeled in large letters to prevent accidents or errors.
Hearing deficits also pose a safety risk, as directions and warnings can
be missed or misinterpreted. Audiometric evaluation should be obtained for
persons with hearing impairments to determine possible corrective
measures and the benefit of hearing aids. Older persons should be advised
not to purchase a hearing aid without an evaluation and prescription for
their specific needs.
Explanations and directions for diagnostic tests, medication
administration, or other therapeutic measures should be explained in
written, as well as verbal, form. Hearing-impaired individuals should live
close to someone with adequate hearing, who can alert them when fire
alarms or other warnings are sounded. Specially trained dogs for the
hearing impaired, similar to seeing-eye dogs, may prove useful; local
hearing and speech associations can provide information on this and other
resources.
COMMUNICATION TIP
Vision and hearing limitations of older adults produce difficulties for
care providers who need to communicate necessary questions,
warnings, or directions during the night. Whispering to avoid
awakening other sleeping individuals may be missed by the older
person who has a reduced ability to hear or whose hearing aid is
removed, and lip reading is difficult in dimly lit bedrooms. Focusing a
flashlight on the lips of the speaker can help the individual read lips,
and cupping the hands over the ear and speaking directly into it can
aid hearing. A stethoscope also can be used to amplify conversation
by placing the earpieces into the individual’s ear and speaking into the
bell portion. It is a good idea to explain these procedures during the
day so that the patient will understand your actions during the night.
KEY CONCEPT
Conversation with a hearing-impaired individual during the night can be
facilitated by placing the earpieces of a stethoscope into the impaired
person’s ears and speaking into the bell or diaphragm.
Other sensory deficits, although more subtle, can predispose older

adults to serious risks. A decreased sense of smell can cause older adults to
miss odors that can help them to differentiate between harmful and
harmless substances. Because older adults may not be able to detect a gas
odor before gas intoxication occurs, electric stoves may be better options
than gas stoves. The loss of taste receptors may cause older adults to use
excessive amounts of salt and sugar in their diets, which is a possible health
hazard. Reduced tactile sensation to pressure from shoes, dentures, or
unchanged positions can lead to skin breakdown, and the inability to
differentiate between temperatures can cause burns. Nurses should plan
careful observation, education, and environmental modifications to
compensate for specific deficits.
Addressing Risks Associated With Mobility

Limitations
Slower response and reaction times may be safety hazards. Older
pedestrians may misjudge their ability to cross streets as traffic lights
change, and older drivers may not be able to react quickly enough to avoid
accidents; if family members are not available to escort and transport these
individuals, assistance may be obtained through local social service
agencies. Slower movement and poor coordination subject older adults to
falls and other accidents; loose rugs, slippery floors, clutter, and poorly
fitting slippers and shoes should be eliminated. Because poor judgment,
denial, or lack of awareness of their limitations may prevent them from
protecting themselves, older people should be advised not to take risks,
such as climbing ladders or sitting on ledges to wash windows.

Temperature fluctuations can be hazardous to older individuals. The normal
body temperature of many older persons is lower than that found in younger
persons (e.g., temperatures as low as 97°F [36°C] can be a normal finding
in older adults). Temperature elevation indicating a health problem can be
missed if one is not aware of the person’s baseline norm. For instance, a
99°F (37°C) temperature may not be alarming to the caregiver; however, if
it is 2°F above the individual’s norm, an infection may be present and, if
undiscovered, can lead to complications. In addition to having an
undetected, untreated, underlying problem, an unrecognized temperature
elevation places an added burden on the heart. For every 1°F elevation, the
heart rate increases approximately 10 beats/min—a stress that older hearts
do not tolerate well. At the other extreme, hypothermia develops more
easily in older people and can cause serious complications and death.
Because the risk of developing infections is considerably greater in older
persons than in younger adults, avoiding situations that contribute to
infection is necessary. Contact with persons who have known or suspected
infections should be avoided, as should crowds (e.g., in shopping malls,
classrooms, and movie theaters) during flu season.
Vaccines should be kept up-to-date. The CDC recommends that persons
aged over 65 years, nursing home residents, and persons who have close
contact with either of these groups be vaccinated against influenza annually.
Although pneumococcal vaccines had been administered once in a lifetime,
the current recommendations for adults age 65 years or older are (Centers
for Disease Control and Prevention, 2019c) as follows:
If they have never received any type of pneumococcal vaccine, they

should receive PCV13 (pneumococcal conjugate vaccine) first,
followed by PPSV23 (pneumococcal polysaccharide vaccine) 6 to 12
months later (PCV13 and PPSV23 should not be administered at the
same time).
For those who have already received PPSV23, they should also be
given one dose of PCV13 at least 1 year after receiving PPSV23.
For those who need PPSV23 revaccination, revaccinate at least 5 years
after the last dose of PPSV23 and 6 to 12 months after receiving
PCV13.
Tetanus vaccines every 10 years should also be current.

In addition to avoiding external sources of infection, older adults must
be careful to ensure they do not create situations that predispose them to
infection, such as immobility, malnutrition, and poor hygiene. Of course,
good infection control practices are a must for preventing iatrogenic
infections in older persons who receive services from health care providers.

In addition to receiving the recommended vaccines, avoiding immobility,
consuming a well-balanced diet, and adhering to other sound health
practices can reduce the risk of infection.
Some evidence suggests that the herbs echinacea, goldenseal, and garlic
can help prevent infection and that ginseng can assist with infection
prevention by protecting the body from the ill effects of stress.

Shoes that are too large, offer poor support, or have high heels can lead to
falls, as can loose hosiery and robes or pants legs that drag on the floor.
Garters and tight-fitting shoes or garments can obstruct circulation. Hats
and scarves can decrease the visual field. Clothing that is practical, properly
fitting, and conducive to activity is advisable.
The high number of drugs consumed by older adults and the differences in
the pharmacokinetics in the aged can lead to serious adverse effects. Drugs
should be prescribed only when necessary and after nonpharmacologic
measures of treatment have proved ineffective. Older adults and their
caregivers should be taught the proper use, side effects, and interactions of
all drugs they are taking and be advised in the discrete use of over-the-
counter drugs. (See Chapter 15 for more information on drugs.)
KEY CONCEPT
Among the drugs identified by the Beers criteria as being fall-risk
medications are anticholinergics, barbiturates, benzodiazepines,
psychotropics, digoxin, and clonidine.
Avoiding Crime
Older adults are particularly vulnerable to criminals who view them as
ready targets. In addition to being victims of actual crimes, older adults
often are so fearful of potentially becoming victims of crime that they may
be reluctant to leave their homes. Reasonable discretion should be used in
traveling alone or at night and in opening doors to strangers. Likewise,
older people should use caution in negotiating contracts and seek the advice
of family members or professionals as needed. Gerontological nurses may
want to identify crime prevention programs offered in the community by
law enforcement agencies, faith communities, senior centers, and other
groups; if such programs are not available, nurses can assist in their
development.

There is a growing number of older drivers on the road. Unfortunately, the
risk of being injured or killed in a motor vehicle crash increases with age,
with fatal crash rates beginning to rise at age 75 and increasing significantly
after age 80 (Centers for Disease Control and Prevention, 2019d). Slow
responses, the effects of medications that can reduce alertness, poor vision,
and altered cognition are among the reasons older drivers can be at risk for
driving accidents.
Nurses should assist older drivers in identifying risks to safe driving
and encourage them to evaluate their continued ability to drive safely. They
also should educate older adults about the reality that driving is a complex
skill requiring rapid cognitive and psychomotor responses and that age-
related changes (e.g., reduced peripheral vision, sensitivity to glare, and
slower response and reaction times) can affect responses, even in the
absence of diseases and medications. Rather than cease driving altogether,
some older adults may find it useful to restrict their driving to daylight
hours, noncongested areas, and good weather. Local chapters of the
Automobile Association of America, the American Association of Retired
Persons, and senior citizen groups can be contacted for safe driving classes
that could be offered to older adults. If such programs do not exist in the
community, the gerontological nurse could stimulate interest and assist in
developing programs as a means of advocating for the safety of older
drivers.
POINT TO PONDER
Many people take calculated risks, such as exceeding the speed limit,
practicing unsafe sex, abusing drugs, and failing to perform regular
breast self-examinations. What risks do you take and why do you do so?
What can you do to change this behavior?

The early identification and correction of health problems help minimize
risks to safety. Regular professional assessment is important; however, self-
evaluation by older adults can be equally beneficial because they will
recognize changes or abnormalities in themselves that signal problems.
Nurses can teach older adults how to perform the following measures:
Take their own temperature and pulse (do not assume that everyone
knows the right way to use and read a thermometer or palpate a pulse)
Listen to their own lungs with a stethoscope (they may not be able to
diagnose the sounds they hear, but they will be able to recognize a new
or changed sound)
Observe changes in their own sputum, urine, and feces that could
indicate problems
Identify the effectiveness, side effects, and adverse reactions of their
medications
Recognize symptoms that should warrant professional evaluation
Confusion, disorientation, poor judgment, and decreased memory

handicap older adults’ ability to protect themselves from hazards to their
health and well-being. When these symptoms occur, they are not to be taken
lightly or accepted as normal. Often, the root of the problem can be a
reversible disorder, such as hypotension, hypoglycemia, or infection. A
thorough assessment is crucial to selecting the appropriate treatment
modality and correcting the problem before complications occur.
A review of the individual’s behaviors and function can pinpoint
potential safety risks. Examples of situations to note include the following:
Smoking in bed
Incontinence
Inappropriate use of a walker or other mobility aid
Dizziness resulting from a new medication
Driving a car with poor vision
Cashing Social Security checks in a high-crime area
Excessive alcohol consumption
Use of recreational drugs or drugs prescribed for others
Having an active pet that is constantly underfoot
Nurses can identify these risks by observing and asking about routine
activities, responsibilities, and typical tasks performed. Steps to correct
potential problems should be taken before an incident occurs.
Yoder • Part 2
Recall from Chapter 5 Sherman “Red” Yoder,

who has lived alone on his farm for 10 years since his wife died and drives
20 miles into town weekly to visit with friends. Red’s son and daughter-in-
law live nearby and manage the farm. He has a diabetic foot wound, which
makes it difficult for him to walk and drive. What effect can life events of
older adulthood have on his psychosocial function? What nursing
interventions by the home health nurse can promote psychosocial wellness
for Red? What technology resources can contribute to his quality of life
and psychosocial well-being? (Red Yoder’s story continues in Chapter 19.)
Addressing Risks Associated With Functional

Impairment
A particularly high risk to safety exists when persons are functionally
impaired, such as in Alzheimer’s disease. Cognitively impaired individuals
may not understand the significance of symptoms, may lack the capability
to avoid hazards, and may be unable to communicate needs and problems to
others. Examples of specific impairments that could heighten safety risks
include significant memory deficits, disorientation, dementia, delirium,
depression, deafness, low vision, aphasia, and paralysis.
When such conditions exist, an assessment should be made to
determine how activities of daily living (e.g., food preparation, telephone
use, medication administration, laundry, and housekeeping) are affected.
Interventions are then planned to address specific problems and can include
the following:
Referring the individual to occupational therapists, audiologists,

ophthalmologists, psychiatrists, and other specialists for evaluation of
the existing condition and prescription of appropriate treatment
Providing assistive devices and mobility aids and instruction in their
use
Helping the person to prepare and label drugs for unit dose
administration; develop a triggering and recording system for drug
administration
Arranging for telephone reassurance, home health aid, home-delivered
meals, housekeeper, emergency alarm system, or other community
resources to assist the impaired person
Instructing and supporting family caregivers as they supervise and care
for the impaired individual
Modifying the individual’s environment to reduce hazards and
promote function
Fear of Falling Among Community-Dwelling

Older Adults: A Scoping Review to Identify
Effective Evidence-Based Interventions
Source: Whipple, M. O., Hamel, A. V., & Talley, K. M. C. (2018). Geriatric
Nursing, 39(2), 170–177.
Fear of falling is estimated to affect between 20% and 39% of older
adults who reside in the community. This fear is present in persons who
have and have not fallen. When this fear is present, people tend to reduce
physical and social activity as well as quality of life. Although using good
judgment to prevent falls is beneficial to older adults, a fear of falling that
reduces activity can have negative effects. This study reviewed clinical
trials aimed at improving the fear of falling in community-based older
adults.
Interventions to reduce the fear of falling were shown to have various
degrees of success. Exercises that proved helpful in reducing the fear of
falling included tai chi, walking, and water-based training. No one type of
exercise proved better than others. Cognitive behavioral therapy was
commonly used in multicomponent interventions. Combining
psychotherapy with exercise was shown to be effective.
Because fear of falling could reduce activity and negatively affect
physical, mental, and social activity, exploring this problem during
assessment can prove beneficial. It could be easy for this fear to be
undetected in older adults unless specific questions to reveal its presence
are asked (e.g., Do you have any concerns about falling? Do you limit your
activities in any way to avoid falling?). Older adults with this fear can be
provided information on basic fall prevention strategies (e.g., balance and
strength training, safe shoes, observing walking surface, wearing prescribed
eyeglasses, environmental modifications) while being encouraged to
maintain activity. Exercises can be taught based on their capabilities and
risks. Specific concerns or fears that these individuals have should be
reviewed and addressed. In addition, guided relaxation and cognitive
behavioral therapy can aid in reducing fear about falling and promoting safe
activity.
PRACTICE REALITIES
Mrs. Dean is an 85-year-old nursing home resident. She has good cognitive
function but an unsteady gait due to the effects of a past stroke and
generalized weakness. Although she has had physical therapy and knows
how to use a walker, Mrs. Dean has fallen a few times in the past several
months. Although the falls have only resulted in bruises, Mrs. Dean’s
daughter is concerned that her mother is going to fall and sustain a serious
fracture, so she asks the nursing staff to have Mrs. Dean use a wheelchair
and not ambulate.
What is the best action for the staff to take?

1. Explain how Maslow’s theory of low-level needs having to be fulfilled
before one can concentrate on the fulfillment of high-level needs
relates to satisfaction from one’s environment.
2. What lighting, color selection, and decorations would be most
therapeutic for the following areas used by older persons?
Bedroom
Recreation room
Dining room
3. List at least six hazards for older adults in the average bathroom.
4. What measures can be taken to humanize an institutional environment?
5. Describe the safety risks that could result from the following health
problems: hypertension, arthritis, right-sided weakness, and
Alzheimer’s disease.
6. What changes could be made to the average home to make it user
friendly and safe for older adults?
7. What content could be included in a program to educate older adults
about actions they can take to avoid accidents and injuries?

questions.
The primary nurse in the rehabilitation unit is

providing a discharge report to a home health
nurse regarding a 74-year-old male client who is
being discharged home with his wife.Nurse’s
Notes
1100:
The primary nurse reports that the client was admitted 14 days ago to the
rehabilitation unit from the orthopedic unit for strengthening related to
status after a right hip open reduction internal fixation (ORIF). The client
was found on the bathroom floor at home by his wife, who said she did
not realize he had fallen. He was brought to the emergency room by the
emergency medical services. The client indicated that he got dizzy and
fell. His wife said he took his blood pressure medication too many times
because he did not remember taking it. Blood pressure on arrival to the
emergency room was 60/40, and pulse was 58. He was given 500 mL of
normal saline intravenously in the emergency room.
After a comprehensive assessment and diagnostic workup in the
emergency room, the client was diagnosed with right hip fracture,
hypotension relating to drug overdose, urinary tract infection (UTI), and
pneumonia. He has a history of high blood pressure and early stage
Alzheimer’s disease. The client was later admitted to the orthopedic unit.
He had an ORIF 2 weeks ago, right hip incision dry and intact with Steri-
Strip in place. His staples were removed yesterday. Client is alert but
disoriented to time and place; his gait is unsteady, and he uses a rolling
walker for ambulation with close assistance. He has completed his IV
antibiotics for the treatment of his UTI and pneumonia. Last night, he
had a productive cough of yellow material, and he sustained a skin tear to
his left arm when he was trying to remove the bilateral wrist restraint
(which was applied because he was pulling his IV line out). The restraint
was discontinued. The discharge order is for home health nurse visits
four times a week for management of medications (metropolol 50 mg
twice a day and donepezil 5 mg at bedtime) and physical therapy three
times a week for restoration of ambulation. Vital signs are BP 140/94
with metroprolol 40 mg given by mouth 30 minutes ago, pulse 74,
respiration 20, and temperature 98.6°F oral.
Chapter Summary
The effects of age-related changes, the impact of the multiple conditions
older adults often possess, and the large number of medications used
increase the risk for injuries in older adults and contribute to accidents
being the sixth leading cause of death for this population. Falls rank as the
leading cause of fatal and nonfatal injuries in older adults, and the rate of
fire deaths in the home is higher among older adults as compared to other
age groups.
Basic factors in the environment—such as lighting, temperature, colors,
floor coverings, furniture, and noise—can affect safety and require
evaluation and adjustment as needed. Fall risk should be assessed in every
clinical and residential setting, and interventions to reduce the risk should
be implemented. Risks arising from individuals’ sensory deficits, reduced
mobility, medication use, living conditions, immunity, functional
impairments, and ability to meet nutrition and hydration needs are
important to identify. Older adults and their caregivers can benefit from a
regular review of safety risks and actions to reduce them.
Online Resources
AAA Foundation for Traffic Safety Senior Driver Web Site
http://seniordriving.aaa.com
Try This: Best Practices in Nursing Care to Older Adults Issue 8, Fall Risk
Assessment: Hendrich II Fall Risk Model
http://consultgerirn.org/uploads/File/trythis/try_this_8.pdf
National Institute on Aging
Older Drivers
https://www.nia.nih.gov/health/older-drivers
References
Ayalew, M. B., Tegegn, H. G., & Abdela, O. A. (2019). Drug related hospital admission: A
systematic review of the recent literatures. Bulletin of Emergency and Trauma , 7 (4), 339–346.
Bolton, L. (2019). Preventing fall injury. Wounds , 31 (10), 269–271.
Centers for Disease Control and Prevention. (2019a). Deaths, percentage of total deaths, and death
rates for the 10 leading causes of death in selected age groups, by race and Hispanic origin and
sex: United States, 2017. Retrieved February 2, 2020 from
https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68_06-508.pdf
Centers for Disease Control and Prevention. (2019b). Injury prevention & control: Facts about older
adult falls. Retrieved February 2, 2020 from https://www.cdc.gov/injury/features/older-adult-
falls/index.html
Centers for Disease Control and Prevention. (2019c). Recommended adult immunization schedule
for ages 19 years or older, United States 2019. Retrieved February 15, 2020 from
https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html
Centers for Disease Control and Prevention. (2019d). Older adult drivers. Retrieved February 15,
2020 from https://www.cdc.gov/motorvehiclesafety/older_adult_drivers/index.html
U.S. Fire Administration. (2019). U.S. fire deaths, fire death rates, and risk of dying in a fire.
Retrieved February 3, 2020 from https://www.usfa.fema.gov/data/statistics/fire_death_rates.html
http://thepoint.lww.com/Eliopoulos10e to access the Recommended
Readings and other additional resources associated with this chapter.
CHAPTER 15
Safe Medication Use
Chapter Outline
Effects of Aging on Medication Use
Promoting the Safe Use of Drugs
Avoiding Potentially Inappropriate Drugs: Beers Criteria
Reviewing Necessity and Effectiveness of Prescribed Drugs
Alternatives to Drugs
Review of Selected Drugs
Analgesics
Antacids
Antibiotics
Anticoagulants
Anticonvulsants
Digoxin
Diuretics
Laxatives
Psychoactive Drugs
LEARNING OBJECTIVES
1. Describe the unique aspects of drug pharmacokinetics and

pharmacodynamics in older people.
2. List measures to promote safe drug use.
3. Describe alternatives to medications.
4. Identify proper uses and risks associated with common drug groups
used with older adults.
TERMS TO KNOW
Beers criteriaoriginally developed by a group headed by Dr. Mark H.
Beers; listing of drugs that carry high risks for older adults and criteria
for potentially inappropriate medication use in older adults
Biological half-lifethe time necessary for half of a drug to be excreted
from the body
Pharmacokineticsrefers to the absorption, distribution, metabolism, and
excretion of drugs
Pharmacodynamicsrefers to the biologic and therapeutic effects of drugs
at the site of action or on the target organ
Polypharmacyuse of multiple medications
When caring for older adults, it is important for the nurse to understand
special considerations for medication use in the older population. Drugs act
differently in older adults than in younger adults and require careful dosage
adjustment and monitoring. Older adults are also more likely than other
populations to take more than one medication regularly, increasing the risk
of interactions and adverse reactions. To minimize the risks associated with
drug therapy and ensure that medications do not create more problems than
they solve, close supervision and adherence to sound principles of safe drug
use are essential in gerontological nursing.
EFFECTS OF AGING ON
MEDICATION USE
Medication use in older adults presents special challenges because of the
number of drugs commonly used, age-related changes that affect drug
pharmacokinetics and pharmacodynamics, and an increased risk of adverse
reactions (Fig. 15-1).
FIGURE 15-1 The high prevalence of drugs consumed by
older people and the complexity of drug dynamics in old
age require gerontological nurses to evaluate regularly the
continued need, appropriateness of dosage, and intended
and adverse effects of every drug given to older
individuals.

The high prevalence of health conditions in the older population causes this
group to use a large number and variety of medications. Drug use by older
adults has been steadily increasing every year. Most older people use at
least one drug regularly, with the median being seven prescribed
medications (Williams, Miller, Khoury, & Grossberg, 2019). Being
prescribed five or more medications is considered polypharmacy.
Polypharmacy occurs in more than one third of older adults and more than
one half when over-the-counter drugs are included (Gabauer, 2020). The
most commonly used drugs by the older population include the following:
Cardiovascular agents
Antihypertensives
Analgesics
Antiarthritic agents
Sedatives
Tranquilizers
Laxatives
Antacids
The drugs on this list can cause adverse effects (e.g., confusion,
dizziness, falls, and fluid and electrolyte imbalances) that threaten older
people’s quality of life. Furthermore, when taken together, some of these
drugs can interact and cause serious adverse effects (Table 15-1).
TABLE 15-1 Interactions Among Popular Drug Groups

Arrows indicate the effect of drugs listed in the left-hand column on those listed across the top.
KEY CONCEPT
A common interaction that often is not considered is the effects of
caffeine on medications. A high caffeine intake can decrease the effects
of antiarrhythmics, cimetidine, iron, and methotrexate; heighten the
hypokalemic effects of diuretics; and increase the stimulant effects of
amantadine, decongestants, fluoxetine, and theophylline.
Taking more than one drug also increases the risk of drug–food
interactions (Table 15-2). When caring for older adults, particularly those
taking more than one medication, it is important for nurses to monitor for
signs of possible interactions.
TABLE 15-2 Examples of Food and Drug Interactions

POINT TO PONDER
How often do you rely on medications to curb appetite, promote sleep,
stimulate bowel elimination, or manage a headache or some other
symptom? Why do you choose to use medications rather than address
the underlying cause or use a natural means to correct the problem? How
can you change this?
Pharmacokinetics refers to the absorption, distribution, metabolism, and
excretion of drugs.
Absorption
Generally, older people have fewer problems in the area of drug absorption
than with distribution, metabolism, and excretion of drugs. However, a
variety of factors can alter drug absorption, such as the following:
Route of administration. Drugs given intramuscularly, subcutaneously,

orally, or rectally are not absorbed as efficiently as drugs that are
inhaled, applied topically, or instilled intravenously.
Concentration and solubility of drug. Drugs that are highly soluble
(e.g., aqueous solutions) and in higher concentrations are absorbed
with greater speed than less soluble and less concentrated drugs.
Diseases and symptoms. Although once considered outcomes of aging
because they are commonly present, decreased intracellular fluid,
increased gastric pH, decreased gastric blood flow and motility,
reduced cardiac output and circulation, and slower metabolism can
slow drug absorption and are more the result of underlying disease
states than normal age-related changes. Conditions such as diabetes
mellitus and hypokalemia can increase the absorption of drugs,
whereas pain and mucosal edema will slow absorption.
Although nurses can do little to improve many of the underlying factors

responsible for altered drug absorption, they can use measures to maximize
the absorption of drugs. Exercise stimulates circulation and aids in
absorption. Properly used heat and massage likewise increase blood flow at
the absorption site. Preventing fluid volume deficit, hypothermia, and
hypotension is beneficial in facilitating absorption. Preparations that
neutralize gastric secretions should be avoided if a low gastric pH is
required for drug absorption. The nurse should monitor for interactions
discussed previously that may affect drug absorption. Consideration should
also be given to using the most effective administration route for the drug.
Distribution
Although it is difficult to predict with certainty how drug distribution will
differ among older adults, changes in circulation, membrane permeability,
body temperature, and tissue structure can modify this process. For
example, adipose tissue increases compared with lean body mass in older
persons, especially in women; therefore, drugs stored in adipose tissue (i.e.,
lipid-soluble drugs) will have increased tissue concentrations, decreased
plasma concentrations, and a longer duration in the body. Decreased cardiac
output can raise the plasma levels of drugs while reducing their deposition
in reservoirs; this is particularly apparent with water-soluble drugs.
Reduced serum albumin levels can be problematic if several protein-bound
drugs are consumed and compete for the same protein molecules; the
unbound drug concentrations increase and the effectiveness of the drugs
will be threatened. Highly protein-bound drugs that may compete at
protein-binding sites and displace each other include acetazolamide,
amitriptyline, cefazolin, chlordiazepoxide, chlorpromazine, cloxacillin,
digitoxin, doxycycline, furosemide, glyburide, hydralazine, ibuprofen,
naproxen, nortriptyline, phenytoin, propranolol, rifampin, salicylates,
spironolactone, sulfisoxazole, tolbutamide, and warfarin. When monitoring
the blood levels of medications, it is also important to evaluate the serum
albumin level. For instance, raising the dosage of phenytoin because the
blood level is low can lead to toxicity if the serum albumin is also low.
KEY CONCEPT
When several drugs are taken concurrently, protein-bound drugs may not
achieve desired results because of ineffective binding to reduced protein
molecules.
Conditions such as dehydration and hypoalbuminemia decrease drug

distribution and result in higher drug levels in the plasma. When these
conditions exist, lower dosage levels may be necessary.
Metabolism, Detoxification, and Excretion

Conditions such as dehydration, hyperthermia, immobility, and liver disease
can decrease the metabolism of drugs. As a consequence, drugs can
accumulate to toxic levels and cause serious adverse reactions. Careful
monitoring is essential. Along this line, the extended biological half-life of
many of the drugs consumed by older adults warrants close evaluation of
drug clearance. Estimated creatinine clearance must be calculated based on
the age, weight, and serum creatinine level of the individual because serum
creatinine levels alone may not reflect a reduced creatinine clearance level.
In advanced age, there may be a reduced secretion of some enzymes,
which interferes with the metabolism of drugs that require enzymatic
activity. Among these is the cytochrome P-450 enzyme system that aids in
the metabolism of bioactive substances (e.g., herbs) in addition to
medications. When two or more substances that utilize the cytochrome P-
450 enzyme system are used concurrently, they compete for the reduced
enzymes and are metabolized more slowly. In addition, the detoxification
and conjugation of drugs may be significantly reduced, so that the drug
stays in the bloodstream longer. Some evidence indicates larger drug
concentrations at administration sites in older persons.
The renal system is primarily responsible for the body’s excretory
functions, and among its activities is the excretion of drugs. Drugs follow a
path through the kidneys similar to that of most constituents of urine. After
systemic circulation, the drug filters through the walls of glomerular
capillaries into the Bowman’s capsule. The drug continues down the tubule,
where substances beneficial to the body will be reabsorbed into the
bloodstream through proximal convoluted tubules and where waste
substances excreted through the urine flow into the pelvis of the kidney.
Capillaries surrounding the tubules reabsorb the filtered blood and join to
form the renal vein. It is estimated that to promote this filtration process,
almost 10 times more blood circulates through the kidneys than through
similarly sized body organs. The reduced efficiency of body organs with
advanced age affects the kidneys as well, complicating drug excretion in
older adults. Nephron units are decreased in number, and many of the
remaining ones can be nonfunctional in older individuals. The glomerular
filtration rate and tubular reabsorption are reduced. Decreasing cardiac
function contributes to the almost 50% reduction in blood flow to the
kidneys. The implications of reduced kidney efficiency are important.
Drugs are not as quickly filtered from the bloodstream and are present in
the body longer. The biological half-life, or the time necessary for half of
the drug to be excreted, can increase as much as 40% and increase the risk
of adverse drug reactions. Drugs that have a likelihood of accumulating
because of an increased biological half-life include antibiotics, barbiturates,
cimetidine, digoxin, and salicylate.
KEY CONCEPT
The extended biological half-life of drugs in older adults increases the
risk of adverse reactions.
The liver also has many important functions that influence drug
detoxification and excretion. Carbohydrate metabolism in the liver converts
glucose into glycogen and releases it into the bloodstream when needed.
Protein metabolism in the parenchymal cells of the liver is responsible for
the loss of the amine groups from amino acids, which aid in the formation
of new plasma proteins, such as prothrombin and fibrinogen, as well as in
the conversion of some poisonous nitrogenous by-products into nontoxic
substances such as vitamin B12. Also important is the liver’s formation of
bile, which breaks down fats through enzymatic action and removes
substances such as bilirubin from the blood. The liver decreases in size and
function with age, and hepatic blood flow declines. This could affect the
metabolism of some drugs, such as antibiotics, cimetidine,
chlordiazepoxide, digoxin, lithium, meperidine, nortriptyline, and
quinidine.
Pharmacodynamics refers to the biologic and therapeutic effects of drugs
at the site of action or on the target organ. Information on
pharmacodynamics in the older population has been limited but is growing
as increased research is done in this area. At this point, some of the known
differences in older adults’ responses to drugs include increased myocardial
sensitivity to anesthesia and increased central nervous system (CNS)
receptor sensitivity to narcotics, alcohol, and bromides.
It is estimated that every day 750 older adults are hospitalized for problems
related to medications (Lown Institute, 2019). The risk of adverse reactions
to drugs is so high in older people that nurses should assess for this
complication with every assessment and consider the relationship of new
symptoms to medications being used. The following are some general
factors to remember in regard to adverse reactions:
The signs and symptoms of an adverse reaction to a given drug may

differ in older persons.
A prolonged time may be required for an adverse reaction to become
apparent in older adults.
An adverse reaction to a drug may be demonstrated even after the drug
has been discontinued.
Adverse reactions can develop suddenly, even with a drug that has
been used over a long period of time without problems.
KEY CONCEPT
The risk of adverse drug reactions is high in older adults because of age-
related differences in pharmacokinetics and pharmacodynamics.
Varying degrees of mental dysfunction often are early symptoms of

adverse reactions to commonly prescribed medications for older adults,
such as codeine, digitalis, methyldopa, phenobarbital, l-dopa, diazepam
(Valium), and various diuretics. Any medication that can promote
hypoglycemia, acidosis, fluid and electrolyte imbalances, temperature
elevations, increased intracranial pressure, and reduced cerebral circulation
also can produce mental disturbances. Even the most subtle changes in
mental status could be linked to a medication and should be reviewed with a
physician. Older adults easily may become victims of drug-induced
cognitive dysfunction. Unfortunately, mental and behavioral dysfunction in
older adults is sometimes treated symptomatically (i.e., with medications
but without full exploration of the etiology). This approach will not correct
a drug-related problem and can predispose the individual to additional
complications from the new drug.
KEY CONCEPT
Nurses should ensure that drug-induced cognitive and behavioral
problems are not treated with additional drugs.
PROMOTING THE SAFE USE OF

DRUGS
Avoiding Potentially Inappropriate Drugs: Beers

Criteria
In 1991, Dr. Mark H. Beers et al. published a paper that identified drugs
that carry high risks for older adults. Since that time, this work has been
developed further to provide criteria for potentially inappropriate
medication use in older adults (The 2019 American Geriatrics Society
Beers Criteria Update Expert Panel, 2019). Beers criteria included drugs
that were inappropriate to use in general (Box 15-1) and drugs that were
inappropriate to use in the presence of specific conditions (Table 15-3).
Some of the major drugs of concern include anticholinergics, tricyclic
antidepressants (TCAs), antipsychotics, barbiturates (except when used as
anticonvulsants), and benzodiazepines. These criteria have been widely
accepted in geriatric care circles as a means to reduce both adverse drug
effects and drug costs. In fact, the Centers for Medicare and Medicaid
Services have adopted the criteria for use in nursing home surveys and the
Joint Commission also adopted the criteria as a potential sentinel event in
hospitals.
TABLE 15-3 Examples of Potentially Inappropriate Drugs to
Use in Older Adults in the Presence of Specific Diagnoses or
Conditions
Source: The 2019 American Geriatrics Society Beers Criteria Update Expert Panel. (2019). American
Geriatrics Society 2019 Updated Beers Criteria for potentially inappropriate medication use in older
adults, Table 3. 2019 American Geriatrics Society Beers Criteria for potentially inappropriate
medication use in older adults due to drug–disease or drug–syndrome interactions that may
exacerbate the disease or syndrome. Journal of the American Geriatrics Society , 67 (4), 674–694.
BOX 15-1 Potentially Inappropriate Drugs to

Use in Older Adults
The following drugs were identified as having a high risk of adverse
reactions in older adults:
First-generation antihistamines (as single agent or as part of

combination products): brompheniramine, carbinoxamine,
chlorpheniramine, clemastine, cyproheptadine, dexbrompheniramine,
dexchlorpheniramine, diphenhydramine (oral), doxylamine,
hydroxyzine, promethazine, pyrilamine, triprolidine
Anti-Parkinson agents: benztropine (oral), trihexyphenidyl
Antispasmodics: atropine (except ophthalmic), belladonna alkaloids,
clidinium–chlordiazepoxide, dicyclomine, hyoscyamine, propantheline,
scopolamine
Antithrombotics: dipyridamole (oral short acting)
Anti-infective: nitrofurantoin
Cardiovascular: disopyramide; dronedarone, digoxin (>0.125 mg/d),
nifedipine (immediate release), spironolactone (>25 mg/d)
Peripheral alpha-1 blockers: doxazosin, prazosin, terazosin
Central alpha-agonists: clonidine, guanabenz, guanfacine, methyldopa,
reserpine (>0.1 mg/d)
Central nervous system:
Antidepressants, alone or in combination: amitriptyline, amoxapine,
clomipramine, desipramine, doxepin (>6 mg/d), imipramine,
nortriptyline, paroxetine, protriptyline, trimipramine
Antipsychotics, first (conventional) and second (atypical) generation
Barbiturates: amobarbital, butabarbital, butalbital, mephobarbital,
pentobarbital, phenobarbital, secobarbital
Benzodiazepines: short and intermediate acting: alprazolam, estazolam,
lorazepam, oxazepam, temazepam, triazolam; long acting: clorazepate,
chlordiazepoxide, chlordiazepoxide (alone or with amitriptyline or
clidinium), diazepam, flurazepam, quazepam
Meprobamate
Nonbenzodiazepine hypnotics: eszopiclone, zolpidem
Ergoloid mesylates: isoxsuprine
Endocrine: androgens: methyltestosterone, testosterone; desiccated
thyroid; estrogens with or without progestins; growth hormone; insulin
(sliding scale); megestrol; sulfonylureas (long duration):
chlorpropamide, glyburide
Gastrointestinal: metoclopramide; mineral oil, given orally; proton
pump inhibitors
Pain medications:
Meperidine
Non–cyclooxygenase-selective NSAIDs, oral: aspirin (>325 mg/d),
diclofenac, diflunisal, etodolac, fenoprofen, ibuprofen, ketoprofen,
meclofenamate, mefenamic acid, meloxicam, nabumetone, naproxen,
oxaprozin, piroxicam, sulindac, tolmetin
Indomethacin, ketorolac, includes parenteral
Skeletal muscle relaxants: carisoprodol, chlorzoxazone, cyclobenzaprine,
metaxalone, methocarbamol, orphenadrine
Source: The 2019 American Geriatrics Society Beers Criteria Update Expert Panel. (2019).
American Geriatrics Society 2019 Updated Beers Criteria for potentially inappropriate
medication use in older adults, Table 2. 2019 American Geriatrics Society Beers Criteria for
potentially inappropriate medication use in older adults due to drug–disease or drug–
syndrome interactions that may exacerbate the disease or syndrome. Journal of the American
Geriatrics Society , 67 (4), 674–694.
Reviewing Necessity and Effectiveness of

Prescribed Drugs
The scope of drug use and significant adverse reactions that can result
necessitate that gerontological nurses ensure drugs are used selectively and
cautiously. Nurses should review all prescription and nonprescription
medications used by patients and ask themselves these questions:
Why is the drug ordered? Consider whether the drug is really needed.
Perhaps warm milk and a back rub could eliminate the need for the
sedative; maybe the patient had a bowel movement this morning and
now does not need the laxative. The medication may be used because
it has been prescribed for years and no one has considered its
discontinuation.
Is the smallest possible dosage ordered? Older adults usually require
lower dosages of most medications because of the delayed time for
excretion of the substance. Larger dosages increase the risk of adverse
reactions.
Is the patient allergic to the drug? Sometimes the physician may
overlook a known allergy, or perhaps the patient neglected to share an
allergy problem with the physician. The nurse may be aware of a
patient’s sensitivities to certain drugs. Consideration must also be
given to new signs that could indicate a reaction to a drug that has
been used for a long period without trouble.
Can this drug interact with other drugs, herbs, or nutritional
supplements that are being used? It is useful to review resource
material to identify potential interactions—they are too numerous for
anyone to commit to memory!
Are there any special instructions accompanying the drug’s
administration? Some drugs should be given on an empty stomach and
others with a meal. Certain times of the day may be better for drugs to
be given than others.
Is the most effective route of administration being used? A person who
cannot swallow a large tablet may do better with a liquid form.
Suppositories that are expelled because of ineffective melting or oral
drugs that are vomited obviously will not have the therapeutic effect of
the drug given in a different manner.
CONSIDER THIS CASE

Mr. Mansfield, a widowed 76-year-old
man who lives alone, is visiting his primary care physician for a follow-up
appointment. He takes several medications, which he has brought with
him to the visit. In reviewing the medications, the nurse notices that an
antibiotic prescribed last month that was to be completed over a 10-day
period still has half of the prescription remaining. Upon being questioned,
Mr. Mansfield admits that he “may have forgotten to take the pills
sometimes.” When reviewing with Mr. Mansfield the other medications he
is taking, the nurse notes that Mr. Mansfield appears to have difficulty
reading the labels and doesn’t recall the purpose or dosage of the various
medications. “I usually do okay with them, but it is a lot to remember,” he
states.
THINK CRITICALLY
1. What additional information would be useful for the nurse to
obtain in assessing Mr. Mansfield’s medication administration
capabilities?
2. What measures could be suggested to Mr. Mansfield to improve

his medication administration?
Nurses must go through a mental checklist of these questions when
administering medications and teach older persons who are responsible for
their own medication administration, as well as their caregivers, to do the
same.
KEY CONCEPT
Regular review of a drug’s ongoing necessity and effectiveness is
essential.

The most common way to administer drugs is orally. Oral medications in
the form of tablets, capsules, liquids, powders, elixirs, spirits, emulsions,
mixtures, and magmas are used either for their direct action on the mucous
membrane of the digestive tract (e.g., antacids) or for their systemic effects
(e.g., antibiotics and tranquilizers). Although oral administration is simple,
certain problems can interfere with the process. Dry mucous membranes of
the oral cavity, common in older individuals, can prevent capsules and
tablets from being swallowed. If they are then expelled from the mouth,
there is no therapeutic value; if they dissolve in the mouth, they can irritate
the mucous membrane. Proper oral hygiene, ample fluids for assistance
with swallowing and mobility, proper positioning, and examining the oral
cavity after administration will ensure that the patient receives the full
benefit of the medicine during its travel through the gastrointestinal (GI)
system. Some older people may not even be aware that a tablet is stuck to
the roof of their dentures or under their tongue.
KEY CONCEPT
To ensure that oral medications achieve full benefit, encourage good oral
hygiene, ample fluids, and proper positioning to facilitate swallowing.
Because enteric-coated and sustained-release tablets should not be
crushed, the nurse should consult with a physician for an alternative form of
the drug if a tablet is too large to be swallowed. As a rule, capsules are not
to be broken open and mixed. Medications are put into capsule form so that
unpleasant tastes will be masked or the coating will dissolve when it comes
into contact with specific GI secretions. Some vitamin, mineral, and
electrolyte preparations are bitter, and even more so for older persons,
whose taste buds for sweetness are lost long before those for sourness and
bitterness. Combining the medication with foods and drinks such as
applesauce and juices can make them more palatable and prevent gastric
irritation, although there may be a problem if the full amount of medicated
food is not ingested. Individuals should be informed that the food or drink
they are ingesting contains a medication. Oral hygiene after the
administration of oral drugs prevents an unpleasant aftertaste.
Drugs prescribed in suppository form for local or systemic action are
inserted into various body cavities and act by melting from body heat or
dissolving in body fluids. Because circulation to the lower bowel and
vagina is decreased and the body temperature is lower in many older
individuals, a prolonged period may be required for the suppository to melt.
If no alternative route can be used and the suppository form must be given,
a special effort must be made to ensure that the suppository is not expelled.
Intramuscular and subcutaneous administration of drugs is necessary
when immediate results are sought or when other routes cannot be used,
because of either the nature of the drug or the status of the individual. The
upper, outer quadrant of the buttocks is the best site for intramuscular
injections. Frequently, the older person will bleed or ooze after the injection
because of decreased tissue elasticity; a small pressure bandage may be
helpful. Alternating the injection site will help to reduce discomfort.
Medication should not be injected into an immobile limb because the
inactivity of the limb will reduce the rate of absorption. For a person
receiving frequent injections, the nurse should check for signs of infection
at the injection site; reduced subcutaneous sensation in older persons or
absence of sensation, as that experienced with a stroke, may prevent the
person from being aware of a complication at the injection site.
Occasionally, intravenous administration of drugs is necessary. In
addition to observing the effects of the medication, the nurse needs to be
alert to the amount of fluid in which the drug is administered. Declining
cardiac and renal function make older people more susceptible not only to
dehydration but also to overhydration. The nurse must closely monitor for
signs of circulatory overload, including elevated blood pressure, increased
respirations, coughing, shortness of breath, and symptoms associated with
pulmonary edema. Intake and output balance, body weight, and specific
gravity are useful to monitor. Of course, the nurse should also monitor older
patients for complications associated with intravenous therapy in any age
group, for example, infiltration, air embolism, thrombophlebitis, and
pyrogenic reactions. Decreased sensation may mask any of these potential
complications, emphasizing the necessity for close nursing observation.
KEY CONCEPT
Older adults are at risk for circulatory overload during intravenous drug
therapy; close monitoring is essential.

Because so many older people are responsible for self-medication, nurses
should promote self-care capacity in this area. The nurse should assess a
patient’s risk for medication errors (Box 15-2) and plan interventions to
minimize those risks. Some of the factors that could interfere with safe drug
administration include the following:
BOX 15-2 Risk Factors for Medication Errors

Use of multiple medications
Cognitive impairment
Hearing deficits
Arthritic or weak hands
History of noncompliance with medical care
Lack of knowledge regarding medications
Limited finances
Illiteracy
Lack of support system
History of inappropriate self-medication
Presence of expired or borrowed medications in home
Functional limitations: Impairments in the person’s ability to perform

activities of daily living or instrumental activities of daily living could
create challenges in the ability to administer medications. These
problems could include the inability to travel to a pharmacy to have a
prescription filled, problems removing lids from medication
containers, difficulty pouring the drugs or obtaining fluids to take with
them, and impaired swallowing.
Cognitive limitations: Older adults could have impairments that
prevent them from remembering to take the medications, make them
forget that they did take the medication and retake them, and cause
them to confuse medications, dosage, or schedule.
Educational limitations: Persons with limited education may have
difficulty reading and understanding instructions and labels.
Sensory limitations: Hearing deficits can cause instructions to be
missed or misunderstood. Poor vision can prevent labels and
instructions from being adequately seen.
Financial limitations: Limited funds could cause the older person to
not fill prescriptions, skip dosages, or use an old prescription or
someone else’s similar medication.
Choice: Some individuals may make a conscious decision to not take
their medications due to dislike of the effects, poor motivation,
preference to use funds for other purposes, or denial of their condition.
COMMUNICATION TIP
A visit with the health care provider can be very stressful for older
adults, which can increase the risk that instructions pertaining to
medications can be misunderstood or forgotten. To aid in ensuring
instructions are understood and followed, a detailed written
description should be given to older people and their caregivers,
outlining the drug’s name, dosage schedule, route of administration,
action, special precautions, incompatible foods or drugs, and adverse
reactions (Fig. 15-2). A color-coded dosage schedule can assist
persons who have visual deficits or who are illiterate. Medication
labels with large print and caps that can be easily removed by weak or
arthritic hands should be provided.
During every patient–nurse visit, the nurse should review the patient’s
medication schedule and new symptoms. A variety of potential
medication errors can be prevented or corrected by close monitoring.
Some of the classic self-medication errors include incorrect dosage,
noncompliance arising from misunderstanding, discontinuation or
unnecessary continuation of drugs without medical advice, and the use
of medications prescribed for previous illnesses. Box 15-3 describes
guidelines to use in teaching older adults about safe drug use.
BOX 15-3 Tips for Safe Drug Use: Teaching

Tool
Keep a current list of all of the following that you use and show it
to your health care providers:
Prescription drugs
Over-the-counter drugs
Vitamins, minerals, and other nutritional supplements
Herbal and homeopathic remedies
For each drug, herb, homeopathic remedy, or nutritional supplement
that you use, know (and, if possible, have this information written
down) the following:
Dosage
Administration schedule
Administration instructions (take on full or empty stomach,
take only if symptom is present, discontinue after x days)
Purpose
Usual side effects
Adverse effects that you should bring to the attention of your
health care provider
Precautions (when you should not take it; interactions with
food, other drugs, or substances)
Storage instructions
Where purchased/obtained
Learn as much as you can about the drugs you are taking by reading
the literature that comes with the drug and consumer drug reference
books that are available at your local library or bookstore.
Recognize that your drug dosage may be different from someone
else’s dosage who is taking the same drug.
Be aware that you can develop adverse effects to drugs that you
have taken for years without problems. Review any symptoms you
have with your health care provider.
Try to reduce the drugs you are using. Discuss with your health care
provider improvements in your symptoms or other changes that
could cause a drug to no longer be needed.
Periodically review your drug dosages with your health care
provider to see if any changes in your body’s function could lead to
reduced dosages.
Try to manage new symptoms naturally rather than with drugs.
Do not take new drugs without consulting your health care provider.
FIGURE 15-2 The nurse teaches the older adult about his
medications to promote safe self-care.

Blood tests often are done to determine the blood levels of certain
medications and to assess if the drug is achieving the desired result. This
monitoring is especially important for older adults as their body functions
can change over time, thereby altering the metabolism and excretion of
medications. In addition, drugs can behave differently in older persons.
Lack of adherence to administration schedules can also be determined
through laboratory testing.
Nurses should consult with the physician and pharmacist as to the type
and frequency of blood work necessary for specific medications. For
community-based older adults, it is important to assure they can travel to
the site of laboratory testing; limited mobility, unavailability of help to
transport or escort them, lack of funds, and poor memory could interfere
with obtaining the necessary testing.
ALTERNATIVES TO DRUGS
Older adults have many health conditions for which drugs can prove
helpful. However, drugs can produce serious adverse effects that can result
in greater threats to older persons than their primary health conditions. It is
crucial that drugs be used cautiously and that the benefits and risks of drugs
be weighed to ensure they result in more good than harm.
Sometimes, lifestyle changes can improve conditions and eliminate the
need for medications. These can include diet modifications, regular
exercise, effective stress management techniques, and regular schedules for
sleep, rest, and elimination.
Alternative and complementary therapies provide new avenues for
treating health conditions. These therapies have grown in acceptance and
popularity among consumers and can offer effective and safe approaches to
managing health conditions. Often, alternative therapies can replace the
need for drugs or enable lower dosages of drugs to be used. It is crucial for
nurses to be aware of the uses, limitations, precautions, and possible
adverse reactions associated with alternative therapies so that they can help
older adults be informed consumers.
POINT TO PONDER
How can you envision using alternative and complementary therapies as
substitutes for or adjuncts to drug therapy in your practice? What
obstacles could you face in attempting to integrate these therapies into
your practice and what could you do to overcome them?
REVIEW OF SELECTED DRUGS

The remainder of this chapter reviews major drug groups and the main
concerns related to their use in the older population. This section is not
intended to be an all-inclusive drug review; readers are advised to consult
with current drug references and pharmacists for comprehensive
information.
Analgesics
With the high prevalence of pain among older adults, analgesics are widely
used. Of the analgesics, the nonsteroidal anti-inflammatory drug (NSAID)
aspirin is particularly popular because of its effectiveness and low cost.
Older adults are especially sensitive to the effects of aspirin and more likely
to experience side effects. Of the various side effects of aspirin, GI bleeding
is one of the most serious. When iron deficiency anemia is detected in older
persons, it is important to inquire about aspirin consumption, which could
be related to GI bleeding. Using buffered or enteric-coated aspirin
preparations and avoiding taking aspirin on an empty stomach are helpful
measures in preventing GI irritation and bleeding. Insomnia can occur when
patients are using caffeine-containing aspirin products (e.g., Anacin,
Butalbital Compound, Cope, Fiorinal, and Stanback Powder), so it is
important to inquire about the specific brand of aspirin when collecting
drug information from a patient. Occasionally, disturbances of the CNS
develop when persons with decreased renal function use aspirin. Aspirin
suppositories can cause irritation of the rectum. Symptoms related to this
include changes in mental status, dizziness, tinnitus, and deafness. When
patients are on low-sodium diets, consideration must be given to their
aspirin intake as a large intake of sodium salicylate (as could occur with
patients taking aspirin regularly for arthritis) can contribute a significant
amount of sodium to the diet.
Acetaminophen is another popular analgesic among older people with
mild to moderate pain. Despite its relative lack of anti-inflammatory
activity, it often is recommended for the initial treatment of osteoarthritis.
The total daily dose should not exceed 4,000 mg as high doses taken long
term can cause irreversible hepatic necrosis. Liver enzymes can be elevated
with long-term use at lower doses. Acetaminophen doses should be adjusted
for patients with altered liver function. As with aspirin and caffeine
products, acetaminophen products that contain caffeine or pseudoephedrine
hydrochloride (e.g., Dristan Cold No Drowsiness Formula Maximum
Strength Caplets, Excedrin Aspirin-Free Caplets, Sine-Off Maximum
Strength No Drowsiness Formula Caplets, and Sinutab) can cause insomnia.
Acetaminophen can cause false results with some blood glucose tests;
inquiry should be made about the new use of the drug when new alterations
in blood glucose levels are discovered. Patients with renal or liver disease
have a high risk of serious side effects when using acetaminophen.
Opioid use has become a concern for persons of all ages, particularly as
drug overdoses, mainly involving opioids, have become the leading cause
of unintentional injury deaths for all age groups (Centers for Disease
Control and Prevention, 2019). A survey by the National Council on Aging
(2019) has found that a significant number of older adults who had opioid
prescriptions reported theft of these medications by family members.
Although the risk of abuse and adverse reactions should be considered, it
needs to be balanced against the benefit that opioids can offer in managing
pain when other options aren’t effective. Short-acting opioids (codeine,
fentanyl, meperidine, morphine, and oxycodone) are used for mild to
moderate pain and typically would be tried before long-acting opioids
(fentanyl, morphine sustained release, and oxycodone sustained release) are
initiated. When deemed appropriate, opioids should be used with caution
and closely monitored in older adults due to an increased risk of adverse
effects, especially respiratory depression. Common adverse effects of these
drugs include anorexia, constipation, nausea, vomiting, sedation, lethargy,
weakness, risk of falls, confusion, and dependency. Because older adults are
more likely to suffer from prostatic hypertrophy or obstruction and age-
related renal function impairments, they are at risk for experiencing opioid-
induced urinary retention. Meperidine is the least preferred opioid because
older adults are more sensitive to its side effects; also, it is excreted by the
kidney, and because older adults are more likely to have decreased renal
function, the risk of toxic reactions to this drug is high.
Nursing guidelines for older adults taking analgesics include the
following:
Assess the symptom of pain carefully for its underlying cause.

Improving or eliminating the cause of the pain may make the use of an
analgesic unnecessary.
Explore nonpharmacologic means to manage pain, such as relaxation
exercises, massages, warm soaks, and diversional activities.
If nonpharmacological means of pain control are unsuccessful, begin
with the weakest type and dose of analgesic and gradually increase so
that the patient’s response can be evaluated.
Administer analgesics regularly to maintain a constant blood level.
Observe for signs of infection other than fever in patients who are
taking aspirin or acetaminophen as the antipyretic effect of these drugs
can mask fevers associated with infection.
Because bleeding and delayed clotting times can result from long-term
aspirin use, observe for signs of anemia, bleeding, and altered
hemoglobin and prothrombin time (PT).
Note signs of salicylate toxicity, which include dizziness, vomiting,
tinnitus, hearing loss, sweating, fever, confusion, burning in the mouth
and throat, convulsions, and coma.
Observe for hypoglycemic reactions, which can occur when persons
with diabetes combine aspirin with sulfonylureas.
Use narcotics very carefully in older adults.
If there has been a known or suspected overdose of any drug from this
group, refer the patient for emergency help at once, even if no
symptoms are present. Signs of poisoning may not appear for several
days, although liver damage may be occurring.
Be alert to interactions:
Aspirin can increase the effects of oral anticoagulants, oral
antidiabetic agents, cortisone-like drugs, penicillins, and
phenytoin.
Aspirin can decrease the effects of probenecid, spironolactone,
and sulfinpyrazone.
Aspirin’s effects can be increased by large doses of vitamin C and
decreased by antacids, phenobarbital, propranolol, and reserpine.
Acetaminophen’s effects can be decreased by phenobarbital.
Narcotic analgesics can increase the effects of antidepressants,
sedatives, tranquilizers, and other analgesics.
The effects of narcotics can be increased by antidepressants and
phenothiazines; nitrates can increase the action of meperidine.
Meperidine can decrease the effects of eye drops used for the
treatment of glaucoma.
Antacids
Decreased gastric acid secretion and increased intolerance to fatty and fried
foods make indigestion a common occurrence in late life and antacids
popular drugs. It is important, however, that nurses assess the reason for
antacid use. What patients believe to be indigestion actually could be
gastric cancer or ulcer; also, cardiac disorders can present with atypical
symptoms that resemble indigestion. Chronic antacid use could warrant the
need for a diagnostic evaluation.
The availability and widespread use of antacids can cause some
individuals to minimize the seriousness of these drugs. Antacids are drugs,
and they do interact with other medications. Sodium bicarbonate– and
magnesium-containing antacids can cause fluid and electrolyte imbalances
by promoting diarrhea; sodium bicarbonate can cause hypernatremia and
metabolic acidosis; calcium carbonate can lead to hypercalcemia; prolonged
use of aluminum hydroxide can cause hyperphosphatemia; and long-term
use of calcium-based antacids can lead to constipation and renal problems.
Therefore, it is important to use these drugs carefully and only when
needed.
Nursing guidelines for older adults taking antacids include the
following:
During assessments, ask specifically about the use of antacids. Some

patients may not consider over-the-counter antacid medications of
concern and may omit them when reporting their medication histories.
Ensure that patients who have used antacids frequently or over a long
period of time have been evaluated for the underlying cause of their
problem.
Avoid administering other medications within 2 hours of
administration of an antacid, unless otherwise ordered, to prevent the
antacid from interfering with drug absorption.
Monitor bowel elimination. Constipation can result from the use of
aluminum hydroxide and calcium antacids; diarrhea can occur when
magnesium hydroxide combinations are used.
Advise patients who are on sodium-restricted diets to avoid using
sodium bicarbonate as an antacid.
Aluminum hydroxide can increase the effects of meperidine and
pseudoephedrine.
Magnesium hydroxide can increase the effects of dicumarol and
reduce the effects of raltegravir.
Most antacids can decrease the effects of barbiturates,
chlorpromazine, digoxin, iron preparations, isoniazid, oral
anticoagulants, penicillin, phenytoin, salicylates, sulfonamides,
tetracycline, and vitamins A and C.
Antibiotics
Age-related changes in the immune system and the high prevalence of
disease processes cause older adults to be highly susceptible to infections.
Antibiotics can play a role in treating these infections; however, excessive
use of antibiotics has contributed to the emergence and spread of antibiotic-
resistant bacteria. Penicillin resistance in Streptococcus pneumoniae has
increased significantly, as has resistance to macrolides, doxycycline,
trimethoprim–sulfamethoxazole, and second- and third-generation
cephalosporins. Antibiotic-resistant S. pneumoniae is of serious concern
because this pathogen is the leading cause of community-acquired bacterial
pneumonia, bacterial meningitis, and bacterial sinusitis. Oral thrush, colitis,
and vaginitis are common secondary infections from antibiotic therapy that
can cause discomfort and a new set of problems. Further, adverse reactions
to antibiotics occur more frequently in older adults than in other age groups.
With the serious consequences, antibiotic therapy must be used selectively
and cautiously.
Any antibiotic can cause diarrhea, nausea, vomiting, anorexia, and
allergic reactions. Parenteral vancomycin and aminoglycosides (e.g.,
amikacin, gentamicin, and tobramycin) require close monitoring due to the
risk of causing hearing loss and renal failure; renal function tests should be
done regularly during the use of these medications. Fluoroquinolones (e.g.,
ciprofloxacin and moxifloxacin) increase the risk of hypo- and
hyperglycemia in older adults and can cause prolonged QTc intervals; this
group of antibiotics is not used in patients with known prolonged QTc
intervals or who are receiving certain antiarrhythmic agents.
Cephalosporins can cause false results with urine testing for glucose.
Nursing guidelines for older adults taking antibiotics include the
following:
Ensure that cultures are obtained when an infection is suspected or
present; different antibiotics are effective for different infections.
Administer antibiotics on a regular schedule to maintain a constant
blood level. Reinforce to patients that they should not skip doses.
Consider developing a medication chart or calendar to assist the older
patient in remembering to administer the drugs.
Observe for signs of superinfections, which can develop with long-
term use of antibiotics.
Penicillins are protein-bound drugs. When taken with other highly
protein-bound drugs (e.g., aspirin, phenytoin, valproate,
aripiprazole, buspirone, and clozapine), the effects of penicillin
can be reduced, and penicillin, in turn, can reduce the effects of
other protein-bound drugs.
The effects of ampicillin and carbenicillin can be decreased by
antacids, chloramphenicol, erythromycin, and tetracycline.
The effects of doxycycline can be decreased by aluminum-,
calcium-, or magnesium-based laxatives, antacids, iron
preparations, phenobarbital, and alcohol.
The effects of sulfisoxazole can be increased by aspirin,
oxyphenbutazone, probenecid, sulfinpyrazone, and para-
aminosalicylic acid. Sulfisoxazole can increase the effects of
alcohol, oral anticoagulants, oral antidiabetic agents,
methotrexate, and phenytoin.
Probenecid delays the excretion of most antibiotics, with the risk
that their levels will accumulate in the blood and increase the side
effects.
Anticoagulants
Anticoagulants are effective in preventing both arterial and venous
thrombosis and are often prescribed for patients with a history of
thromboembolic disorders, heart attacks, strokes, and coronary disorders, as
well as for prophylaxis for patients who have had hip surgery and mitral
valve replacement. Although beneficial, anticoagulants have a narrow
treatment range and carry a higher risk of bleeding in older persons.
Usually, heparin is prescribed for rapid anticoagulation, followed by
warfarin (Coumadin) for long-term use. Neither of these drugs dissolves
existing clots, but rather prevents the formation of new ones. Heparin is
known to block the eosinophilic response to adrenocorticotropic hormone
and insulin. Osteoporosis and spontaneous fractures are a risk to persons
who have used heparin for a long time.
Nursing guidelines for older adults taking anticoagulants include the
following:
Ensure that patients using anticoagulants have their PT/international

normalization ratio (INR) monitored; discuss the recommended
frequency with the physician.
Age-adjusted dosages may be prescribed; consult with the physician.
Administer anticoagulants at the same time each day to maintain a
constant blood level.
Observe for signs of bleeding; teach patients to observe for these signs.
Educate patients about the need to be careful about diet. A large intake
of vitamin K–rich foods (asparagus, bacon, beef liver, cabbage, fish,
cauliflower, and green leafy vegetables) can reduce the effectiveness
of anticoagulants. Mango and papaya can increase INR. High doses of
vitamin E can increase bleeding risk.
Advise patients to refrain from taking herbal products until they have
reviewed them with their health care provider. Many herbs interact
with anticoagulants.
Keep vitamin K readily available as an antidote when patients are
receiving anticoagulants.
Advise patients to avoid using aspirin as it can interfere with platelet
aggregation and cause bleeding. Three grams or more of salicylates—a
level that could be reached by persons who use aspirin for arthritic
pain—is sufficient to cause hemorrhage in older adults.
Anticoagulants can increase the effects of oral hypoglycemic
agents and phenytoin and decrease the effects of cyclosporine and
phenytoin.
The effects of anticoagulants can be increased by acetaminophen,
allopurinol, alteplase, amprenavir, androgens, aspirin and some
other NSAIDs, azithromycin, bismuth subsalicylate, some
calcium channel blockers, capsaicin, broad-spectrum antibiotics,
chlorpromazine, colchicine, ethacrynic acid, mineral oil,
phenytoin, probenecid, reserpine, thyroxine, tolbutamide, and
TCAs.
The effects of anticoagulants can be decreased by antacids,
antithyroid agents, barbiturates, carbamazepine, chlorpromazine,
cholestyramine, estrogens, rifampin, thiazide diuretics, vitamin K,
ginseng, St. John’s wort, and green tea.
Heparin’s effects can be partially reduced by digoxin,
antihistamines, nicotine, and tetracyclines.
Anticonvulsants
Seizures in older adults can result from a history of epilepsy, injury,
hypoglycemia, infections, electrolyte imbalance, or drug reactions. Treating
many of these conditions can eliminate the seizures and the need for
anticonvulsant drugs; this reinforces the importance of a comprehensive
assessment and diagnostic testing to identify the precise cause.
Anticonvulsants can be used singularly or in combination to sustain a
blood level that will control seizures with the fewest side effects. Older
people have a higher risk of toxicity from anticonvulsants, necessitating that
they be used cautiously. Carbamazepine, lamotrigine, valproate, and
gabapentin are preferred over phenobarbital and phenytoin for treating older
patients with epilepsy.
In addition to seizures, anticonvulsants can be prescribed for the
treatment of bipolar disorders, schizoaffective disorders, chronic
neuropathic pain, prevention of migraines, and other conditions.
Nursing guidelines for older adults taking anticonvulsants include the
following:
Observe for and inquire about possible side effects of these drugs,
including change in bowel habits, abnormal bruising, bleeding, pallor,
weakness, jaundice, muscle and joint pain, nausea, vomiting, anorexia,
dizziness (increasing the risk of falls), blurred vision, diplopia,
confusion, agitation, slurred speech, hallucinations, arrhythmias,
hypotension, sleep disturbances, tinnitus, urinary retention, and
glycosuria.
As these drugs can depress psychomotor activity, ensure patients have
adequate physical activity.
Ensure periodic evaluations of blood levels are done for drugs for
which this is required and/or available (e.g., carbamazepine,
phenytoin, phenobarbital, primidone, and valproic acid).
Be aware that these drugs can worsen any existing liver or kidney
disease.
Anticonvulsants should not be discontinued abruptly. Advise patients
to check with their physicians before discontinuing these drugs.
Advise patients to avoid grapefruit and grapefruit juice when taking
these drugs as grapefruit increases the risk of toxicity.
Monitor closely patients with existing glaucoma, coronary artery
disease, or prostate disease. Anticonvulsants can aggravate these
conditions.
Note that some anticonvulsants can cause photosensitivity.
Anticonvulsants can increase the effects of analgesics,
antihistamines, propranolol, sedatives, and tranquilizers.
Anticonvulsants can decrease the effects of cortisone and
anticoagulants.
The CNS depressant effects can be increased and the
anticonvulsant effects decreased when some anticonvulsants are
used with TCAs.
Anticonvulsants and digitalis preparations taken concurrently
significantly increase the risk of toxicity from both drugs.

Antidiabetic drugs require careful dosage adjustment based on the
individual’s weight, diet, and activity level. Drugs in this group fall under
insulin and sulfonylureas. The self-injection of insulin can be a challenge
for some older adults, particularly those with arthritic hands, poor vision, or
cognitive impairment. Ongoing assessment of the ability of older adults and
their family caregivers to manage injections is essential. People who still
are producing some degree of insulin may take sulfonylureas. Examples
include chlorpropamide, glimepiride, glipizide, glyburide, tolazamide, and
tolbutamide; metformin is not recommended for persons over age 80 years
due to the risk of metabolic acidosis.
Chlorpropamide and glyburide are not drugs of choice for older adults
because they have a long half-life and increase the risk of serious
hypoglycemia.
Hypoglycemia is a more probable and serious problem for older
diabetics than ketosis. Some of the classic signs of hypoglycemia may not
be present in older adults; confusion and slurred speech may give the first
clue of this complication.
See Chapter 24 for more information about the care of the patient who
has diabetes. Nursing guidelines for older adults taking antidiabetic drugs
Teach individuals with diabetes and their caregivers about the proper
use and storage of medications and recognition of hypo- and
hyperglycemia. Reinforce that all insulin or oral antidiabetic drugs are
not interchangeable (i.e., different drugs have different potency, onset,
and duration).
Ensure that people with diabetes wear or carry identification to alert
others of their diagnosis in the event they are found unconscious or
confused.
For patients using insulin, examine injection sites regularly. Local
redness, swelling, pain, and nodule development at the injection site
can indicate insulin allergy. A sunken area at the infection site can be
caused by atrophy and hypertrophy associated with insulin
lipodystrophy—a harmless although unattractive condition.
Report conditions that could alter antidiabetic drug requirements, such
as fever, severe trauma, prolonged diarrhea or vomiting, altered
thyroid function, or heart, kidney, or liver disease.
Advise patients to avoid drinking alcohol as this can lead to a
significant drop in blood sugar.
The effects of antidiabetic drugs can be increased by alcohol, oral
anticoagulants, cimetidine, isoniazid, ranitidine, sulfinpyrazone,
and large doses of salicylates.
The effects of antidiabetic drugs can be decreased by
chlorpromazine, cortisone-like drugs, furosemide, phenytoin,
thiazide diuretics, thyroid preparations, and cough and cold
medications.
Antidiabetic drugs can increase the effects of anticoagulants.
Good circulation becomes increasingly difficult to achieve in later life
because of reduced elasticity of peripheral vessels and the accumulation of
deposits in the lumen of vessels. To compensate for increased peripheral
resistance, systolic blood pressure may rise. Likewise, diastolic blood
pressure may increase in response to an age-related reduction in cardiac
output. Although these increases in blood pressure may compensate for
changes that could interfere with adequate circulation, they create new
associated risks when blood pressure enters a level considered hypertensive
(>140 mm Hg systolic and/or >90 mm Hg diastolic).
Because diuretics blunt the sodium- and water-retaining effects of many
other antihypertensive drugs such as beta-blockers, they are the most
commonly used medication in combination antihypertensive agents.
Diuretics cause blood vessels to dilate and help the kidneys eliminate salt
and water, thereby decreasing fluid volume throughout the body and
lowering blood pressure. Beta-blockers stop the effects of the sympathetic
division, the part of the nervous system that can rapidly respond to stress by
increasing blood pressure. Examples include acebutolol, atenolol, betaxolol,
bisoprolol, carteolol, metoprolol, nadolol, penbutolol, pindolol, propranolol,
and timolol. Side effects of beta-blockers can include dizziness, fainting,
bronchospasm, bradycardia, heart failure, possible masking of low blood
sugar levels, impaired peripheral circulation, insomnia, fatigue, shortness of
breath, depression, Raynaud’s phenomenon, vivid dreams, hallucinations,
sexual dysfunction, and, with some beta-blockers, an increased triglyceride
level.
Angiotensin-converting enzyme (ACE) inhibitors (e.g., lisinopril) are
well-tolerated antihypertensive drugs and are popular initial agents in the
treatment of hypertension. They dilate arterioles by preventing the
formation of angiotensin II, which causes arterioles to constrict and block
the action of ACE, which converts angiotensin I to angiotensin II. Examples
include benazepril, captopril, enalapril, fosinopril, lisinopril, moexipril,
perindopril, quinapril, ramipril, and trandolapril. Cough is a common side
effect of this drug. In patients for whom ACE inhibitor and diuretic
combinations are indicated but not tolerated, angiotensin II receptor
antagonist (e.g., losartan) and diuretic combinations may be used.
Calcium channel blockers cause arterioles to dilate by a completely
different mechanism. Examples include amlodipine, diltiazem (sustained
release only), felodipine, isradipine, nicardipine, nifedipine (sustained
release only), nisoldipine, and verapamil. Side effects of these drugs include
headache, dizziness, flushing, fluid retention, problems in the heart’s
electrical conduction system (including heart block), bradycardia, heart
failure, enlarged gums, and constipation. ACE inhibitors and calcium
channel blockers may be prescribed in combination to lower blood pressure,
as may other combinations.
Alpha-blockers (doxazosin, prazosin, and terazosin) and angiotensin II
blockers (candesartan, eprosartan, irbesartan, losartan, telmisartan, and
valsartan) are among the other drugs that could be prescribed for
hypertension management.
Nursing guidelines for older adults taking antihypertensive drugs
Assess blood pressure carefully. Obtain readings with the patient in

lying, sitting, and standing positions.
Help patients in learning and using nonpharmacologic measures to
reduce blood pressure, such as weight reduction, restriction of sodium
and alcohol intake, moderate aerobic exercise, and stress management
techniques.
Monitor patients closely when therapy is initiated. Some
antihypertensives can cause significant hypotension initially. Advise
patients to change positions slowly to prevent falls. If diuretics are
prescribed, monitor for diuretic-induced dehydration. Because
thiazide-induced adverse events are common in older adults (Liang,
Ma, Cao, Yan, & Yang, 2017), monitor and observe for signs (e.g.,
hyponatremia, hypokalemia, and acute renal dysfunction).
Consult with prescribing physician or NP regarding advising patients
to administer these drugs at bedtime. Research has shown that better
blood pressure control and fewer cardiovascular complications (e.g.,
cardiovascular disease, myocardial infarction, heart failure, stroke)
result when these drugs are taken at bedtime versus in the morning
(Hermida et al., 2019).
Ensure that patients obtain laboratory work as ordered. Monitoring of
serum potassium is especially important when patients are receiving
ACE inhibitors with potassium or potassium-sparing diuretics.
Monitor patients for side effects.
Reinforce to patients the importance of adhering to treatment even
when symptoms are absent.
Some antihypertensives should not be abruptly discontinued. Advise
patients to check with their physicians before discontinuing these
drugs.
Antihypertensive drugs can increase the effects of barbiturates,
insulin, oral antidiabetic drugs, sedatives, and thiazide diuretics.
The effects of antihypertensives can be decreased by
amphetamines, antacids, antihistamines, salicylates, and TCAs.
Verapamil can increase the blood digoxin level.
The effects of propranolol can be increased by cimetidine,
ciprofloxacin, and diuretics.
Grapefruit juice can affect the bioavailability and alter the effects
of calcium channel blockers.
Individual drugs have specific interactions; carefully review drug
literature to learn about them.

The high prevalence of arthritis in the older population contributes to the
wide use of NSAIDs. These drugs are effective in relieving mild to
moderate pain and inflammation; however, they usually are not used unless
lower-risk analgesics (e.g., acetaminophen) have failed to be beneficial.
Examples of NSAIDs include diclofenac, diflunisal, flurbiprofen,
indomethacin, meclofenamate, naproxen, piroxicam, salicylates, and
tolmetin.
Cyclooxygenase-2 (COX-2) inhibitors are a class of NSAIDs
introduced in 1998 that were believed to have the advantage of causing less
gastric irritation. They are called COX-2 inhibitors because they block an
enzyme called cyclooxygenase, which is believed to trigger pain and
inflammation in the body. In 2005, a Food and Drug Administration (FDA)
advisory committee concluded that COX-2 inhibitors increase the risk of
heart attacks and strokes. However, the FDA agreed to allow some of these
drugs (celecoxib [Celebrex]) to be sold because, for many people, the
benefits of the drugs outweighed the cardiovascular risks. When patients are
taking celecoxib, careful monitoring is necessary. Side effects to observe for
include swelling of the face, fingers, hands, and lower legs; severe stomach
pain; and signs of bleeding. People who are allergic to sulfa drugs may have
allergic reactions to celecoxib.
Any NSAID can cause or worsen renal failure, raise blood pressure, and
exacerbate heart failure. Nursing guidelines for older adults taking NSAIDs
NSAIDs have a narrowed therapeutic window, and toxic levels

accumulate much easier and at lower doses in older adults. Closely
observe for and ask about side effects, such as GI symptoms, impaired
hearing, and indications of CNS disturbances. Be aware that older
adults are at higher risk of developing delirium as a side effect to these
drugs.
Ensure blood evaluations are done regularly.
Administer these drugs with food or a glass of milk, unless
contraindicated, to reduce GI irritation.
If patients are using aspirin for cardioprotective effects and are started
on an NSAID, review this with the physician or pharmacist as some
NSAIDs (e.g., ibuprofen) can reduce the cardiac benefit of aspirin.
Prolonged use of indomethacin, meclofenamate, piroxicam, and
tolmetin can cause CNS effects (e.g., headache, dizziness, drowsiness,
and confusion). When reviewing patients’ drugs, note if these drugs
have been used for an extended time and review this with the
physician and pharmacist.
NSAIDs can increase the effects of oral anticoagulants, insulin,
oral antidiabetic drugs, cyclosporine, lithium, penicillin,
phenytoin, and sulfa drugs; they can decrease the effects of
diuretics and beta-blockers.
When celecoxib is used with aspirin, lithium, or fluconazole,
there is an increased risk of serious side effects.
Increasing numbers of aging individuals are alert to the risks associated
with elevated levels of low-density lipoprotein (LDL) cholesterol. Direct-
to-consumer marketing of cholesterol-lowering drugs has also increased the
awareness of this problem. The result has been a growing use of
cholesterol-lowering drugs. These drugs have shown benefit in reducing
cardiovascular events and mortality in older adults.
The main goal in lowering cholesterol is to lower LDL and raise high-
density lipoprotein (HDL). Treatment goals are individualized, based on the
unique profile of the individual patient. Often, prior to initiating therapy,
other interventions are used (e.g., eating a heart-healthy diet, exercise
programs, and weight reduction). Cholesterol-lowering drugs include
statins, niacin, bile acid resins, fibric acid derivatives, and cholesterol
absorption inhibitors.
Statins (HMG-CoA reductase inhibitors), usually the first line of
treatment, block the production of cholesterol in the liver. Examples include
rosuvastatin (Crestor), atorvastatin (Lipitor), fluvastatin (Lescol), lovastatin
(Mevacor), pravastatin (Pravachol), and simvastatin (Zocor). There also are
combination statins, such as Advicor, a combination of a statin and niacin,
and Caduet, a combination of a statin (atorvastatin) and the antihypertensive
amlodipine (Norvasc). As these drugs can impair liver function, liver
function tests should be done prior to initiating therapy and at regular
intervals thereafter. Muscle pain is an important symptom to note in patients
using statins as these drugs can cause myopathy and the breakdown of
skeletal muscle, which can precipitate renal failure. Common side effects
include headache, drowsiness, muscle aches, dizziness, change in bowel
habits, and abdominal cramping.
Niacin, or nicotinic acid, is a B complex vitamin that—in addition to
being available in the diet—can be prescribed at high dosages to lower LDL
and raise HDL cholesterol. Examples include Niacor, Niaspan, and Slo-
Niacin. The main side effects are flushing, itching, tingling, and headache;
aspirin can reduce many of these symptoms. Niacin can interfere with
glucose control and aggravate diabetes. It also can exacerbate gallbladder
disease and gout.
Bile acid resins work inside the intestine, where they bind to bile and
prevent it from being reabsorbed into the circulatory system. Examples
include cholestyramine (Questran and Questran Light), colestipol
(Colestid), and colesevelam (WelChol). The most common side effects are
constipation, gas, and upset stomach. These drugs can interact with
diuretics, beta-blockers, corticosteroids, thyroid hormones, digoxin,
valproic acid, NSAIDs, sulfonylureas, and warfarin; consult with the
physician and pharmacists as to the length of time to wait between the
administration of these drugs and bile acid resins.
Fibric acid derivatives, although their mechanism of action is not fully
clear, are thought to enhance the breakdown of triglyceride-rich particles,
decrease the secretion of certain lipoproteins, and induce the synthesis of
HDL. Examples include fenofibrate (Tricor), gemfibrozil (Lopid), and
fenofibrate (Lofibra). Liver function tests and complete blood count should
be evaluated prior to initiating therapy and on a regular basis thereafter.
Cholesterol absorption inhibitors work by inhibiting the absorption of
cholesterol in the intestines. Vytorin is a newer drug that is a combination of
ezetimibe (Zetia) and the statin simvastatin.
Nursing guidelines for older adults taking cholesterol-lowering drugs
Assist patients in implementing dietary and lifestyle modifications to

help reduce cholesterol levels.
Ensure that patients receive liver functions and other necessary tests as
ordered.
Monitor for interactions and follow precautions for each category of
cholesterol-lowering drugs as discussed above.

With nearly 6 million people suffering from dementia and many more
having some type of memory disorder, there has been increasing
development of drugs to improve cognitive functions. These drugs can slow
the progression of cognitive decline in individuals with mild dementia but
not improve function when there is severe cognitive impairment. They
Cholinesterase inhibitors: donepezil (Aricept), galantamine

(Razadyne), rivastigmine tartrate (Exelon), and tacrine (Cognex)
NMDA receptor antagonists: memantine (Namenda)
These drugs can cause many side effects, including nausea; vomiting;
diarrhea; anorexia; weight loss; urinary frequency; muscle cramps; joint
pain, swelling, or stiffness; fatigue; drowsiness; headache; dizziness;
nervousness; depression; confusion; changes in behavior; abnormal dreams;
difficulty falling asleep or staying asleep; discoloration or bruising of the
skin; and red, scaling, itchy skin.
Nursing guidelines for older adults taking cognitive enhancing drugs
Evaluate patients’ mental status, cognition, and activities of daily

living prior to initiation of therapy and periodically thereafter during
prolonged treatment. Monitor for signs and symptoms of GI bleed.
Ensure that patients using tacrine have regular liver function tests.
Recommend that patients on these drugs be reevaluated as their
underlying disorder progresses.
Cholinesterase inhibitors can affect cardiac conduction in patients with
existing conduction disorders or who are using medications that affect
the heart rate. Review potential risks with the physician and
pharmacist.
Avoid abrupt discontinuation of these drugs. Advise patients to check
with their physicians before discontinuing these drugs.
Instruct patients that tacrine is best taken on an empty stomach and
galantamine is best taken with food.
Be alert to interactions with anticholinergics, aspirin (high doses used
for arthritis), cholinergic drugs, cholinesterase inhibitors, long-term
use of NSAIDs, carbamazepine, dexamethasone, phenobarbital,
phenytoin, and rifampin.
Digoxin
Digitalis preparations are used in the treatment of congestive heart failure,
atrial flutter or fibrillation, supraventricular tachycardia, and extrasystoles
to increase the force of myocardial contraction through direct action on the
heart muscle. The resulting improvement in circulation helps to reduce
edema, as well.
Daily doses in older adults ordinarily should not exceed 0.125 mg
except if used to control atrial arrhythmia and ventricular rate. Digoxin
should be used with caution in patients with impaired renal function.
Nursing guidelines for older adults taking digoxin include the
following:
Check and/or instruct patients and their caregivers to check pulse for
rate, rhythm, and regularity prior to administering digoxin.
The usual biological half-life of these drugs can be extended in older
adults, increasing their risk of digitalis toxicity. Signs of toxicity
include bradycardia, diarrhea, anorexia, nausea, vomiting, abdominal
pain, delirium, agitation, hallucinations, headache, restlessness,
insomnia, nightmares, aphasia, ataxia, muscle weakness and pain,
cardiac arrhythmias, and high serum drug levels (although toxicity can
occur in the presence of normal serum levels). Promptly report any
signs of possible toxicity.
Hypokalemia makes patients more susceptible to toxicity. Ensure that
patients consume potassium-rich foods and that serum potassium is
evaluated regularly.
Older adults can present signs of toxicity with normal plasma levels of
the drug. Be certain to monitor for signs.
The effects of digoxin can be increased by alprazolam,
amphotericin, benzodiazepines, carvedilol, cyclosporine,
erythromycin, ethacrynic acid, fluoxetine, guanethidine,
ibuprofen, indomethacin, phenytoin, propranolol, quinidine,
tetracyclines, tolbutamide, trazodone, trimethoprim, verapamil,
and some other drugs.
The effects of digoxin can be decreased by antacids,
cholestyramine, kaolin–pectin, laxatives, neomycin,
phenobarbital, and rifampin.
The risk of toxicity is increased in the presence of hypercalcemia,
when potassium levels are low, or when digitalis preparations are
taken with cortisone, diuretics, parenteral calcium reserpine, and
thyroid preparations.
Diuretics
Diuretics are used in the treatment of a variety of cardiovascular disorders
such as hypertension and congestive heart failure. There are several major
types that work in different ways:
Thiazides: inhibit sodium reabsorption in the cortical diluting site of

the ascending loop of Henle and increase the excretion of chloride and
potassium. Examples include chlorothiazide, hydrochlorothiazide, and
metolazone.
Loop diuretics: inhibit reabsorption of sodium and chloride at the
proximal portion of the ascending loop of Henle. Examples include
bumetanide, ethacrynic acid, and furosemide.
Potassium-sparing diuretics: antagonize aldosterone in the distal
tubule, causing water and sodium, but not potassium, to be excreted.
Examples include amiloride, spironolactone, and triamterene.

Thiazide diuretics assist in lowering blood pressure, although they do
deplete the body of potassium.
Under normal circumstances, older adults are at high risk for

developing fluid and electrolyte imbalances; diuretic therapy increases this
risk considerably. Special attention must be paid to recognizing signs of
imbalances early and correcting them promptly.
Nursing guidelines for older adults taking diuretics include the
following:
Plan an administration schedule that interferes least with the patient’s
schedule. Morning administration is usually preferable.
Monitor intake and output, and assure adequate fluids are consumed.
Teach patients and their caregivers to recognize and promptly report
signs of fluid and electrolyte imbalance: dry oral cavity, confusion,
thirst, weakness, lethargy, drowsiness, restlessness, muscle cramps,
muscular fatigue, hypotension, reduced urinary output, slow pulse, and
GI disturbances.
Because postural hypotension can occur from the use of these drops,
careful attention should be paid to preventing falls.
Observe for signs of latent diabetes, which sometimes can be
manifested during thiazide diuretic therapy.
Observe for signs of metabolic adverse reactions when thiazide
diuretics are used.
Monitor hearing in patients receiving loop diuretics as these drugs can
cause transient ototoxicity.
Diuretics can worsen existing liver disease, renal disease, gout, and
pancreatitis and raise blood glucose in diabetics. Monitor patients with
these conditions carefully.
Ensure serum electrolytes, glucose, and blood urea nitrogen are
evaluated periodically.
Diuretics can increase the effects of antihypertensives and
decrease the effects of allopurinol, digoxin, oral anticoagulants,
antidiabetic agents, and probenecid.
The effects of diuretics can be increased by analgesics and
barbiturates; diuretics’ effects can be decreased by
cholestyramine and large quantities of aspirin (administer these
drugs at least 1 hour before).
Laxatives
Age-related reduction in peristalsis and the tendency of many older adults
to be less active, consume low-fiber diets, and take medications that are
constipating cause constipation to be a common problem.
Nonpharmacologic measures to promote bowel elimination should be used
before resorting to the use of laxatives. When laxatives are necessary, they
should be selectively chosen and used. Laxatives differ in their function:
Bulk formers (e.g., methylcellulose) absorb fluid in the intestines and

create extra bulk, which distends the intestines and increases
peristalsis. They usually take 12 to 24 hours to take effect. Bulk
formers need to be mixed with large amounts of water. These
compounds should not be used when there is any indication of
intestinal obstruction.
Stool softeners (e.g., docusate sodium) collect fluid in the stool, which
makes the mass softer and easier to move. They do not affect
peristalsis; they take effect in 24 to 48 hours.
Osmotics (e.g., magnesium hydroxide) pull fluid into the colon,
causing bowel distension that increases peristalsis. These take effect
within 1 to 3 hours; they are contraindicated when there is the risk of
fecal impaction.
Stimulants (e.g., cascara sagrada) irritate the smooth muscle of the
intestines and pull fluid into the colon, causing peristalsis. They take
effect in 6 to 10 hours. Stimulants can cause intestinal cramps and
excessive fluid evacuation.
Lubricants (e.g., mineral oil) coat fecal material to facilitate its
passage. They take effect in 6 to 8 hours. These compounds are not
recommended for older adults.
Nursing guidelines for older adults taking laxatives include the

following:
Recognizing that it is a common geriatric risk, assist older adults in

preventing constipation.
When patients complain of constipation, assess carefully before
suggesting or administering a laxative.
Reinforce to older adults and their caregivers that laxatives, although
popular, are drugs and can cause side effects and interact with other
drugs.
Teach patients that good fluid intake must accompany the use of bulk-
forming laxatives and stool softeners to prevent the accumulation of
stool leading to bowel obstruction.
Laxatives can reduce the effectiveness of many oral medications
by increasing the speed of their passage through the GI system.
Chronic use of mineral oil can deplete the body’s fat-soluble
vitamins (vitamins A, D, E, and K).
Psychoactive Drugs
Antianxiety Drugs (Anxiolytics)
Financial worries, deaths, crime, illness, and many of the other problems
commonly faced by older adults give legitimate cause for anxiety. Financial
aid, counseling, self-care instruction, and other interventions can yield
better long-term results in treating situational anxiety than a medication
alone, and these measures may also prevent additional problems from
arising as a result of adverse drug reactions. According to the Diagnostic
and Statistical Manual of Mental Disorders (American Psychiatric
Association, 2013), antianxiety medications should be used only when there
is generalized anxiety disorder, panic disorder, anxiety that accompanies
another psychiatric disorder, sleep disorder, significant anxiety in response
to a situational trigger, or delirium, dementia, and other cognitive disorders
with associated behaviors that are well documented, persistent, and not due
to preventable or correctable reasons, and that create such distress or
dysfunction as to make the person a risk to self or others.
When they are deemed necessary, benzodiazepines are common
antianxiety drugs used in older persons. The CNS depressants can include
short-acting benzodiazepines (e.g., alprazolam, estazolam, lorazepam,
oxazepam, and temazepam) and long-acting benzodiazepines (e.g.,
chlordiazepoxide, clonazepam, diazepam, flurazepam, and quazepam).
Older adults are more likely to experience side effects, which could include
dizziness, unsteady gait, drowsiness, slurred speech, and confusion.
Although less common, other side effects could include abdominal or
stomach cramps, increased heart rate, increased perspiration, sensitivity to
light, seizures, and hallucinations. Some patients experience insomnia,
irritability, and nervousness after they discontinue taking these drugs. As
benzodiazepines are on the Beers list of inappropriate drugs for older
adults, they need to be used with utmost care and usually only until the
slower-acting medications have begun to act.
Meprobamate, diphenhydramine, and hydroxyzine are not advised for
use with older adults. Patients who have used meprobamate for a long
period of time can become physically and psychologically dependent on the
drug and need to be weaned from it slowly.
Nursing guidelines for older adults taking anxiolytics include the
following:
Ensure that approaches other than medications have been attempted

prior to having an antianxiety drug prescribed. Even if these measures
were tried and ineffective previously, they should be tried again.
Advise patients to change positions slowly and to avoid operating a car
or machinery that requires mental alertness and fast responses.
Instruct patients to incorporate foods in the diet that can promote
bowel elimination as these drugs can be constipating. Monitor bowel
elimination.
Monitor nutritional status and weight to assure food intake is not
jeopardized by possible lethargy or GI upset.
Advise caution in grapefruit consumption; this fruit can increase the
concentration of these drugs.
Advise patients that several days of administration may be necessary
before clinical effects from the medication are noted and that the
effects could continue several days after the drug is discontinued.
Avoid alcohol when these drugs are used and limit caffeine.
Antianxiety drugs can increase the effects of anticonvulsants,
antihypertensives, oral anticoagulants, and other CNS
depressants.
The effects of antianxiety drugs can be increased by TCAs.
Diazepam can increase the effects of digoxin and phenytoin,
leading to toxicity; diazepam can decrease the effects of
levodopa.
Antidepressants
The incidence of depression increases with age, contributing to it being the
major psychiatric diagnosis in older adults. Depression may be a problem
that some older adults have struggled with throughout their lives or a new
symptom in response to life circumstances that they now face.
There are several different classes of antidepressants available,
including alpha-adrenoceptors (e.g., mirtazapine), dopamine reuptake
blocking compounds (e.g., bupropion), monoamine oxidase inhibitors (e.g.,
selegiline, isocarbozazid, phenelzine), serotonin antagonists (5-
hydroxytryptamine-2 receptor; e.g., nefazodone and trazodone), selective
serotonin–norepinephrine reuptake inhibitors (e.g., duloxetine and
venlafaxine), selective serotonin reuptake inhibitors (SSRIs; e.g.,
citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, and
sertraline), and tricyclic antidepressants (TCAs; e.g., amoxapine,
desipramine, nortriptyline). Of these, the SSRIs tend to be well tolerated
and effective in older adults and typically do not cause cardiotoxicity,
orthostatic hypotension, or anticholinergic effects that often are experienced
with TCAs. Citalopram, sertraline, and escitalopram have fewer drug–drug
interactions. Although popular, TCAs have side effects that can pose risks
to older adults, such as anticholinergic effects, orthostatic hypotension, and
arrhythmias, especially in patients with cardiovascular disease.
Nursing guidelines for older adults taking antidepressants include the
following:
Assess factors contributing to depression. In some situations, obtaining

financial aid, receiving grief counseling, joining a group, and other
actions can improve the cause of the depression and reduce or
eliminate the need for drugs.
Explore the use of other therapies in addition to antidepressants to
improve mood.
Ensure that the lowest effective dosage of the drug is used to reduce
the risk of adverse effects.
Advise patients that several weeks of therapy commonly is required
before improvement is noted.
Monitor the plasma level of the drug. Be aware that dosage adjustment
may be needed.
Observe for, ask about, and report side effects, including diaphoresis,
urinary retention, indigestion, constipation, hypotension, blurred
vision, difficulty voiding, increased appetite, weight gain,
photosensitivity, and fluctuating blood glucose levels.
The dizziness, drowsiness, and confusion that can occur in older adults
can increase the risk of falls, so special precautions are needed.
Dryness of the mouth can be an uncomfortable side effect of these
drugs. Advise patients to use sugarless mints, ice chips, or a saliva
substitute to improve this symptom. Monitor oral health closely
because dry mouth increases the risk of dental disease.
Some antidepressants need to be discontinued gradually. Advise
patients not to abruptly stop taking the drugs.
Observe patients for a worsening of depression symptoms or suicidal
thinking or behavior; bring these findings to the physician’s attention
immediately.
Antidepressants can increase the effects of anticoagulants,
atropine-like drugs, antihistamines, sedatives, tranquilizers,
narcotics, and levodopa.
Antidepressants can decrease the effects of clonidine, phenytoin,
and various antihypertensives.
The effects of antidepressants can be increased by alcohol and
thiazide diuretics.
Bupropion can increase the risk of seizures.
Antipsychotics
Antipsychotic medications are commonly used to treat older adults with
delirium, agitation, and psychosis due to Alzheimer’s disease and
schizophrenia. The effectiveness of antipsychotics in controlling symptoms
has enabled many individuals to improve their quality of life and function;
however, these drugs can have profound adverse effects, necessitating
careful prescription and close monitoring.
There are two major classes of antipsychotic drugs:
First-generation (conventional/typical) agents. Examples include the

following:
chlorpromazine (Thorazine)
fluphenazine (Prolixin)
haloperidol (Haldol)
loxapine (Loxitane)
molindone (Moban)
perphenazine (Trilafon)
pimozide (Orap)
thioridazine (Mellaril)
thiothixene (Navane)
trifluoperazine (Stelazine)
Second-generation (atypical) agents. Examples include the following:
aripiprazole (Abilify)
clozapine (Clozaril)
fluoxetine and olanzapine (Symbyax)
olanzapine (Zyprexa)
paliperidone (Invega)
quetiapine (Seroquel)
risperidone (Risperdal)
ziprasidone (Geodon)
Because they were viewed as having a lower risk of adverse effects and
greater tolerability, the atypical antipsychotics have largely replaced the
conventional/typical agents. However, the atypical antipsychotics have been
found to have their own set of side effects that are of concern in geriatric
care, such as postural hypotension, sedation, and falls. The FDA has
determined that the treatment of behavioral disorders in older patients with
dementia with atypical or second-generation antipsychotic medications is
associated with increased cerebrovascular adverse events and mortality and
issued a black box warning for these drugs (Purse, 2019). These drugs
should only be used for the treatment of schizophrenia and not for
behavioral disturbances associated with dementias.
The serious risks associated with these drugs and the paucity of clinical
trials with psychotropic medications in the older population in general and
in patients with dementia in particular demand that nonpharmacologic
interventions be used before initiating drug therapy. Nonpharmacologic
interventions can include addressing factors that contribute to symptoms,
environmental modifications, behavioral interventions, and treatment of
other conditions.
Nursing guidelines for older adults taking antipsychotics include the
following:
Ensure that patients receive a thorough physical and mental health

evaluation before any antipsychotic drug is prescribed.
Whenever possible, attempt to use other interventions to address
symptoms prior to using antipsychotics.
Antipsychotics should be used for the treatment of specific disorders
and not as a means of managing behavior. Using antipsychotics to
control behaviors alone can be viewed as chemically restraining
patients.
Drugs have a longer biological half-life in older adults; assure the
lowest possible dosage is initially used.
Older adults are more sensitive to the anticholinergic effects of these
medications: dry mouth, constipation, urinary retention, blurred vision,
insomnia, restlessness, fever, confusion, disorientation, hallucinations,
agitation, and picking behavior. They also are at greater risk for
developing extrapyramidal symptoms: tardive dyskinesia,
parkinsonism, akinesia, and dystonia. Observe and report these
symptoms promptly.
Patients taking antipsychotics are at high risk for falls due to the
hypotensive and sedative effects. Implement fall prevention measures
for these individuals.
Constipation is a common side effect of antipsychotics. Advise
patients to include fiber and other foods in diet that promote regular
bowel movement and monitor bowel elimination.
Men with prostatic hypertrophy may develop urinary hesitance and
retention when using antipsychotics. Advise patients and caregivers to
monitor urinary symptoms and report changes promptly.
Gradual weaning rather than abrupt withdrawal from these drugs is
recommended.
Response to these drugs can vary in older adults, necessitating close
monitoring.
The effects of antipsychotics can be reduced by anticholinergic
drugs, phenytoin, and antacids.
Antipsychotics can increase the effects of sedatives and
antihypertensives and decrease the effects of levodopa.
Alcohol can increase the sedative action and depressant effects of
these drugs on brain function.
Sedatives/Hypnotics
Hypnotics and sedatives often are prescribed for older adults for the
treatment of insomnia, nocturnal restlessness, anxiety, confusion, and
related disorders. The dose will determine if the same drug will have a
hypnotic or sedative effect.
Generally, chloral hydrate, diphenhydramine, flurazepam, hydroxyzine,
quazepam, and triazolam are not drugs of choice for older adults for the
management of insomnia.
Because tolerance to sedatives can develop after prolonged use,
continued evaluation of effectiveness is necessary. It is not unusual for
restlessness, insomnia, and nightmares to occur after sedatives are
discontinued.
Nursing guidelines for older adults taking sedatives/hypnotics include
the following:
Before these drugs are used, evaluate factors contributing to insomnia.

Adjusting environmental lighting or temperature, controlling noise,
eliminating caffeine, increasing physical activity, relieving pain, giving
a back rub, and controlling symptoms of diseases can improve sleep
and eliminate the need for a sedative.
Carefully monitor patients who are using sedatives as they are at
higher risk for falls and fractures.
Sedatives and hypnotics can increase the effects of oral
anticoagulants, antihistamines, and analgesics and decrease the
effects of cortisone and cortisone-like drugs.
The effects of sedatives and hypnotics can be increased by
alcohol, antihistamines, and phenothiazines.
There are other groups of drugs that older adults can use. It is
advantageous to learn about drugs before administering them, understand
the impact specific drugs can have on older adults, teach older adults how
to use individual drugs safely, and regularly monitor for side effects and
adverse reactions.
Characteristics Associated With Transition From

Opioid Initiation to Chronic Opioid Use Among
Opioid-Naïve Older Adults
Source: Musich, S., Wang, S. S., Slindee, L., Kraemer, S., & Yeh, C. S.
(2019). Geriatric Nursing, 40(2), 190–196.
Although opioids are primarily used for the management of acute pain
on a short-term basis, individuals with chronic conditions that cause pain
may use these drugs on a long-term basis. The older population is more
likely to have conditions that require long-term pain management;
therefore, they may be among the individuals who become dependent on
opioids and suffer related adverse effects. The researchers conducting this
study found that no published studies existed that examined chronic opioid
use in older adults; they designed this study to determine the prevalence and
characteristics of opioid-naïve older adults who used opioids chronically
(more than 90 days).
The study included persons aged 65 years and older covered by AARP
Medicare Supplement plans who were using opioids chronically and who
had never used them prior to their current use. A sample from the medical
records of these individuals was used. The group who initiated opioid use
was mostly female, white, between the ages of 70 and 75 years, lived in the
South, had high incomes, and were in the higher coverage medical plans.
Hydrocodone, tramadol, and oxycodone were the most commonly
prescribed opioids for this group. Commonly, these individuals also were
using prescriptions for benzodiazepines, NSAIDs, muscle relaxants, and
sedatives. Chronic back pain was the most evident finding among those
who transitioned to chronic opioid use; the individuals most likely to
transition to chronic opioid use were low income females in poor health
with new or chronic back pain who also were using other medications to
manage mental health issues. Unlike findings in other studies, physical
therapy for back pain in this older study group was associated with an
increased likelihood of opioid use. The researchers believed that more
studies on the challenges of pain management in older adults were needed,
especially with the high prevalence of chronic pain in this group.
Although this study may not reflect the situation with all older adults
who use opioids, it does show that a greater understanding of pain
management and opioid use in older adults is needed. Considerations for
gerontological nurses include the need to assess older adults who have a
chronic use of opioids for the ongoing effectiveness of these drugs for pain
management, the presence of side/adverse effects, signs of mental health
problems, and nonpharmacologic measures that are being used for pain
management. The nurse should also consider measures such as cognitive
behavioral therapy and mindfulness. It is important to realize that the fact
that older adults are using prescribed opioids to manage pain associated
with legitimate medical conditions does not prevent them from being
subject to similar adverse effects experienced by younger persons who
abuse these drugs.
PRACTICE REALITIES
Mrs. Hemmings, an 83-year-old who lives alone in the community, is a
patient of a medical practice where, unless an acute situation arises, she
usually is seen by her physician every 6 months. She has six different
prescription drugs, which she takes for hypertension, glaucoma, and
osteoporosis.
On her visit to the medical office today, when her vital signs are taken
by the nurse, her blood pressure is found to be 190/165. When the physician
enters and takes her blood pressure again 15 minutes later, it is found to be
180/160. The physician asks if she has been taking her antihypertensive
medication and diuretic, and she indicates she has. “In fact,” Mrs.
Hemmings says, “I’m running to the bathroom all night long to urinate.”
The physician changes Mrs. Hemmings’ antihypertensive to a more
potent drug and leaves the room.
What should have been done differently prior to the new medication
being prescribed? What could the nurse do to assist Mrs. Hemmings in this
situation?

1. List age-related changes that affect the way in which drugs behave in
older persons.
2. What key points would you include in a program to educate senior
citizens about safe drug use?
3. What interventions could you employ to aid an older adult who has
poor memory to safely administer medications?
4. Review the major drug groups and identify those that address problems
that could potentially be managed with nonpharmacologic means.

questions.
Nurse’s Notes
A 65-year-old male client was brought to the emergency room by his
son due to nose bleeding and bright red blood noted in his stool early this
morning.
1000: The son reports that the client had a bloody stool last night for the
first time. This morning, his stool was bloody as well, and he also had a
small bit of nose bleeding. The client has been taking four cloves of raw
garlic, turmeric powder, ginger, cayenne pepper, and cinnamon with his
meals for over 3 weeks. He indicates that he read in an article that these
herbs prevent coronavirus. Assessment and interview findings: The client
has a history of hypertension and atrial fibrillation. Home medications
are the following daily by mouth: Coumadin 5 mg, aspirin 325 mg, and
Enalapril 5 mg. Upon assessment, the client’s breath sounds are clear
bilaterally, skin pale and clammy to touch, and 2+ pulse irregular. Vital
signs are temperature 98.6°F oral, pulse 98 beats per minute, respiration
18 breaths per minute, blood pressure 98/60, and pulse oximetry reading
94% on oxygen at 2 L/min via nasal cannula. Capillary refill is greater
than 3 seconds. The client is alert and oriented to person, place, and time.
The client’s son states, “Dad often retakes his meds because he does not
remember taking them.” Client says, “I like taking herbal supplements.”
Chapter Summary
The increased prevalence of health conditions in older adults heightens their
medication use. Polypharmacy raises the risk for adverse reactions due to
the potential for drug–drug interactions. In addition, there are differences in
pharmacokinetics, the way in which drugs are absorbed, distributed,
metabolized, and excreted, and in pharmacodynamics, the biologic and
therapeutic effects of the drugs at the site of action. All of these factors
contribute to the increased risk of adverse reactions.
The Beers criteria list of drugs that are potentially inappropriate to use
in older adults has been widely accepted in geriatric care circles as a means
to reduce both adverse drug effects and drug costs. Nurses should review
the medications used by older adults for their appropriateness and discuss
with the prescriber the risks and benefits of medications that are viewed as
inappropriate or potentially high risk. Whenever possible, nurses should
seek alternatives to medications to control symptoms.
Nurses should be familiar with the intended purpose, dosage range,
administration precautions, potential interactions, monitoring needs, and
signs of side effects and adverse reactions with all medications that they
administer to patients. It is important to remember that medications that
have been used for many years by older adults can begin to cause them
problems; these drugs must be considered when new signs and symptoms
appear.
Online Resources
Agency for Healthcare Research and Quality: Opioids
http://www.ahrq.gov/opioids
American Hospital Association: Prescription Opioids: What You Need
to Know
http://www.aha.org/factsheet/2018-02-20-prescription-opioids-what-you-
need-to-know
Centers for Disease Control and Prevention Opioid Overdose
Information for Patients
http://www.cdc.gov/drugoverdose/patients
Food and Drug Administration: Disposal of Unused Medicines: What
You Should Know
http://fda.gov/drugs/safe-disposal-medicines/disposal-unused-medicines-
what-you-should-know
International Nurses Society on Addictions
http://www.intnsa.org
Narcotics Anonymous
https://na.org
National Institute on Aging: Safe Use of Medicines for Older Adults
https://www.nia.nih.gov/health/safe-use-medicines-older-adults
National Institute on Drug Abuse
http://www.drugabuse.gov
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th
ed.). Washington, DC: Author.
Centers for Disease Control and Prevention. (2019). Ten leading causes of injury deaths by age
groups, 2017. Retrieved February 5, 2020 from
https://www.cdc.gov/injury/wisqars/LeadingCauses.html
Gabauer, J. (2020). Mitigating the dangers of polypharmacy in community-dwelling older adults.
American Journal of Nursing , 120 (2), 37.
Hermida, R.C., Crespo, J.J., Dominguez-Sardina, M., Otero, A., Moya, A, et al. (2019). Bedtime
hypertension treatment improves cardiovascular risk reduction: the Hygia Chronotherapy Trial.
European Heart Journal, October 22, 2019, ehz754. Retrieved September 3, 2020 from
https://doi.org/10.1093/eurheartj/ehz754
Liang, W., Ma, H., Cao, L., Yan, W., & Yang, J. (2017). Comparison of thiazide-like diuretics versus
thiazide-type diuretics: A meta-analysis. Journal of Cellular and Molecular Medicine , 21 (11),
2634–2642.
Lown Institute. (2019). Medication overload: America’s other drug problem. Retrieved February 15,
2020 from https://lowninstitute.org/wp-content/uploads/2019/04/medication-overload-lown-
web.pdf
National Council on Aging. (2019). NCOA survey: Opioid crisis harming aging community.
Retrieved February 15, 2020 from https://www.ncoa.org/news/press-releases/ncoa-survey-
opioid-crisis-harming-aging-community/
Purse, M. (2019). Antipsychotics black box warning for elderly patients. Verywellmind. Retrieved
February 20, 2020 from https://www.verywellmind.com/antipsychotic-medications-black-box-
warning-379657.
The 2019 American Geriatrics Society Beers Criteria Update Expert Panel. (2019). American
Geriatrics Society 2019 Updated AGS Beers Criteria for potentially inappropriate medication
use in older adults. Journal of the American Geriatrics Society , 67 (4), 674–694.
Williams, S., Miller, G., Khoury, R., & Grossberg, G. T. (2019). Rational deprescribing in the elderly.
Annals of Clinical Psychiatry , 31 (2), 144–152.
UNIT 4
Geriatric Care
16 Respiration
17 Circulation
21 Mobility
CHAPTER 16
Respiration
Chapter Outline
Effects of Aging on Respiratory Health
Respiratory Health Promotion
Selected Respiratory Conditions
Pneumonia
Influenza
Lung Cancer
Lung Abscess
General Nursing Considerations for Respiratory Conditions
Ensuring Safe Oxygen Administration
Promoting Self-Care
LEARNING OBJECTIVES
1. List the impact of age-related changes on respiratory health.

2. Describe measures to promote respiratory health in older adults.
3. Discuss the risks, symptoms, and care considerations associated with
selected respiratory illnesses.
4. Describe interventions that can aid in preventing complications and
promoting self-care in older persons with respiratory conditions.
TERMS TO KNOW
Bronchiectasiscondition in which there is permanent abnormal widening
of the airways due to inflammation
Chronic obstructive pulmonary disease (COPD)group of diseases
including a form of asthma, chronic bronchitis, and emphysema
Elastic recoilLungs’ ability to expand and contract
Fremitusa vibration felt during palpation of the chest
Kyphosiscurvature of the spine causing bowing out of upper spine
Total lung capacitymaximum volume that lungs can expand during
fullest inspiration
Vital capacitymaximum amount of air that can be expelled following
maximum inspiration
Respiratory health is vital to the older person’s ability to maintain a

physically, mentally, and socially active life. It can make the difference
between a person maximizing opportunities to live life to the fullest and
being too fatigued and uncomfortable to leave the confines of home. A
lifetime of insults to the respiratory system from smoking, pollution, and
infection takes its toll in old age, making chronic lower respiratory diseases
a leading cause of disability and the third leading cause of death in persons
over 65 years of age. However, positive health practices to promote
effective breathing can benefit respiratory health at any age and minimize
limitations imposed by problems.
EFFECTS OF AGING ON
RESPIRATORY HEALTH
The effects of aging create a situation in which respiratory problems can
develop more easily and be more difficult to manage. Changes in the
respiratory system can be noted in upper airway passages. The nose
experiences connective tissue changes that reduce support and can cause
nasal septal deviations that interfere with the passage of air. Reduced
secretions from the submucosal gland cause the mucus in the nasopharynx
to be thicker and harder to expel; this also can cause a chronic tickle in the
throat and coughing. Although it may appear to be a relatively minor
consideration, hair in the nostrils becomes thicker with age and may readily
accumulate a greater amount of dust and dirt particles during inspiration.
Unless these particles are removed and the nasal passage is kept patent,
there may be an interference with the normal inspiration of air. Blowing the
nose and mild manipulation with a tissue may adequately rid the nostrils of
these particles. When particles are difficult to remove, a cotton-tipped
applicator moistened with warm water or saline solution may help loosen
them. Caution should be taken not to insert the cotton-tipped applicator too
far into the nose because trauma can easily result. Any nasal obstruction not
easily removed should be brought to the physician’s attention.
The trachea stiffens due to calcification of its cartilage. Coughing is
reduced due to a blunting of the laryngeal and coughing reflexes. The gag
reflex is weaker due to a reduced number of nerve endings in the larynx.
The lungs become smaller in size and weight with age. Various
connective tissues responsible for respiration and ventilation are weaker.
The elastic recoil of the lungs during expiration is decreased because of
less elastic collagen and elastin, and expiration requires the active use of
accessory muscles. Alveoli are less elastic, develop fibrous tissue, contain
fewer functional capillaries, and have less surface area, thereby reducing
gas exchange. The loss of skeletal muscle strength in the thorax and
diaphragm, combined with the loss of resilient force that holds the thorax in
a slightly contracted position, contributes to the slight kyphosis and barrel
chest seen in many older adults. The net effect of these changes is a
reduction in vital capacity and an increase in residual volume—in other
words, less air exchange and more air and secretions remaining in the lungs.
Further, age-related changes external to the respiratory system can
affect respiratory health in significant ways. A reduction in body fluid and
reduced fluid intake can cause drier mucous membranes, impeding the
removal of mucus and leading to the development of mucous plugs and
infection. Altered pain sensations can cause signals of respiratory problems
to be unnoticed or mistaken for nonrespiratory disorders. Different norms
for body temperature can cause fever to present at an atypically lower level,
potentially being missed and allowing respiratory infections to progress
without timely treatment. Loose or brittle teeth can dislodge or break,
leading to lung abscesses and infections from the aspiration of tooth
fragments. Relaxed sphincters and slower gastric motility further contribute
to the risk of aspiration. Impaired mobility, inactivity, and side effects from
the numerous medications used by the older population can decrease
respiratory function, promote infection, interfere with early detection, and
complicate treatment of respiratory problems. Table 16-1 lists nursing
problems related to respiratory risks associated with aging. Astute
assessment is essential to reducing the morbidity and mortality associated
with these conditions (Assessment Guide 16-1).
TABLE 16-1 Aging and Risks to Adequate Respiration

RESPIRATORY FUNCTION
Much can be determined regarding the status of the respiratory system
through careful observation of the following:
Color: Coloring of the face, neck, limbs, and nail beds can be
indicative of respiratory status. Ruddy, pink complexions often occur
with emphysema and are associated with hypoxia, which is caused by
a high carbon dioxide level in the blood that inhibits involuntary
neurotransmission from the pons to the diaphragm for inspiration. In
the presence of chronic bronchitis, patients can have a blue or gray
discoloration caused by the lack of oxygen binding to the
hemoglobin.
Chest structure and posture: The anteroposterior chest diameter
increases with age—significantly so in the presence of chronic
obstructive pulmonary disease (COPD). Note abnormal spinal
curvatures (e.g., kyphosis, scoliosis, and lordosis).
Breathing pattern: Observe the chest for symmetrical expansion
during respirations, as well as the depth, rate, rhythm, and length of
respirations. Decreased expansion of the chest can be caused by pain,
fractured ribs, pulmonary emboli, pleural effusion, or pleurisy. Ask
the patient to change positions, walk, and cough to see if these
activities result in any changes.
Cough: Note the presence, frequency, and characteristics of any
cough that may be observed.
INTERVIEW
Some older persons may give unreliable accounts of their past respiratory
symptoms or have grown so accustomed to living with their symptoms
that they do not consider them unusual. Specific questions can assist in
revealing disorders, such as the following:
“Do you ever have wheezing, chest pain, or a heavy feeling in your
chest?”
“How often do you get colds? Do you get colds that keep returning?
How do you treat them?”
“How far can you walk? How many steps can you climb before
getting short of breath?”
“Do you have any breathing problems when the weather gets cold or
hot?”
“How many pillows do you sleep on? Do breathing problems (e.g.,
coughing and shortness of breath) ever awaken you from sleep?”
“How much do you cough during the day? During each hour? Can
you control it?”
“Do you bring up sputum, phlegm, or mucus when you cough? How
much? What color? Is it the consistency of water, egg white, or
jelly?”
“How do you manage respiratory problems? How often do you use
cough syrups, cold capsules, inhalers, vapors, rubs, or ointments?”
“Did you ever smoke? If so, for how long and when and why did you
stop? If you currently smoke, how many cigarettes or cigars do you
smoke daily? Do people you live with or spend a lot of time in the
presence of smoke?”
“What kind of jobs have you had over your lifetime? Any in factories
or chemical plants?”
“Do you live or have you lived near factories, fields, or high-traffic
areas?”
More specific questions increase the likelihood of obtaining a full and

accurate history of factors related to respiratory health. Ascertain and
document the dates of influenza and pneumonia vaccines as well.
Palpate the posterior chest to evaluate the depth of respirations,
degree of chest movement, and presence of masses or pain. Normally,
there is bilateral movement during respirations and reduced
expansion of the base of the lungs. Tactile fremitus is usually best felt
in the upper lobes; increased fremitus in the lower lobes occurs with
pneumonia and masses. COPD and pneumothorax can cause a lack of
fremitus in the upper lobes.
Percussion of the lungs should produce a resonant sound.
Auscultation of the lungs should reflect normal bronchial, vesicular,
and bronchovesicular breath sounds; crackles, rhonchi, and wheezes
are abnormal findings. Lung sounds can be diminished in older adults
due to a decrease in tidal volume. If respiratory infections are
suspected and lung sounds are difficult to hear or questionable when
the patient is in a sitting position, have the patient lie on his or her
side and auscultate the lungs; this often assists in hearing abnormal
lung sounds in the affected lung.
Review assessment data for actual and potential nursing diagnoses that
can be used in guiding the care plan.
KEY CONCEPT
Pieces of brittle teeth can break off, be aspirated, and cause respiratory
problems. This reinforces the importance of good oral health and dental
care in late life.
RESPIRATORY HEALTH PROMOTION

The high risk of developing respiratory disorders that every older person
faces warrants the incorporation of preventive measures into all care plans.
Infection prevention is an important component. In addition to the
precautions any adult would take, older persons need to be particularly
attentive to obtaining influenza and pneumonia vaccines and avoiding
exposure to individuals who have respiratory infections.
Also, in addition to basic health practices, special attention to
promoting respiratory activity is important. Nurses should teach all older
adults to do deep breathing exercises several times daily (Fig. 16-1).
Keeping in mind that full expiration is more difficult than inspiration for
older individuals, these exercises should emphasize an inspiratory–
expiratory ratio of 1:3. To help make these exercises routine, link them with
other routines, such as before meals or every time the person sits down to
watch the news. Even healthy, active people can benefit from including
these exercises in their daily activities. Yoga is another practice that can aid
in respiration.
FIGURE 16-1 Breathing exercises should emphasize
forced expiration. A. With one hand on the stomach
(below the ribs) and the other over the middle anterior
chest, the patient should inhale deeply to the count of one.
The hand over the stomach should move outwardly as the
diaphragm and stomach move downward; the hand over
the chest should not move. B. Expire air slowly to the
count of three. The hand over the stomach should be
pulled closer to the body as the diaphragm and stomach
move upward; the hand over the chest should not move.
POINT TO PONDER
Take a few minutes to slow down, close your eyes, and do deep
breathing exercises. What effects did this have on your body, mind, and
spirit? How could these exercises benefit you if you did them several
times throughout the day?
Because smoking is the most important factor contributing to

respiratory disease, smoking cessation is an important health promotion
measure. Many older smokers started their habit at a time when the full
effects of smoking were not realized and smoking was considered
fashionable, sociable, and sophisticated. Although smokers may be aware
of the health hazards associated with smoking, it is an extremely difficult
habit to break.
Smoking has significant effects on the respiratory system, including
bronchoconstriction, early airway closure, reduced ciliary action,
inflammation of the mucosa, and increased mucous secretions and
coughing. The effects on respiratory health may initially be so subtle and
gradual that they are not realized. Unfortunately, by the time signs and
symptoms become apparent, considerable damage to the respiratory system
may have occurred, compounding age-related changes to the system.
Smokers have twice the incidence of lung cancer, a higher incidence of all
respiratory diseases, and more complications with respiratory problems and
commonly suffer from productive coughs, shortness of breath, and reduced
breathing capacity. Nicotine can interact with medications, as well.
Although maximum benefit is obtained by not starting to smoke in the first
place or quitting early in life, smoking cessation is beneficial at any age.
Local chapters of the American Lung Association, health departments,
clinics, and commercial agencies offer a wide range of smoking cessation
approaches that may be useful.
KEY CONCEPT
The use of tobacco in any form carries an increased risk of health
problems.
Immobility is a major threat to pulmonary health, and older adults
frequently experience conditions that decrease their mobility. Preventing
fractures, pain, weakness, depression, and other problems that could
decrease mobility is an essential goal. Older adults, their family members,
and caregivers all need to be educated about the multiple risks associated
with immobility. It may be tempting for the older person to reduce activity
or for caring family members to encourage that person to rest on days when
arthritis or other discomforts are bothersome, unless it is understood that by
doing so, more discomfort and disability can result. When immobility is
unavoidable, hourly turning, coughing, and deep breathing will promote
respiratory activity; blow bottles and similar equipment can also be
beneficial. Persons who are chair-bound may need the same attention to
respiratory activity as the bed-bound to ensure their lungs are fully
expanded.
Older persons should be advised against treating respiratory problems
themselves. Many over-the-counter cold and cough remedies can have
serious effects in older adults and can interact with other medications being
taken. These drugs can also mask symptoms of serious problems, thereby
delaying diagnosis and treatment. Older adults should know that a cold
lasting more than 1 week may not be a cold at all, but something more
serious that requires medical attention.
It is important to review all medications used by older persons for their
impact on respiration. Decreased respirations or rapid, shallow breathing
can be caused by many of the drugs commonly prescribed for geriatric
conditions; these drugs include analgesics, antidepressants, antihistamines,
antiparkinsonian agents, synthetic antispasmodics, sedatives, and
tranquilizers. As always, alternatives to drugs should be used whenever
possible.
Environmental factors also influence respiratory health. Indirect room
ventilation is best for older people who are more susceptible to drafts;
fibrosis, which is common in older people, can be aggravated by chilling
and drafts. Considerable attention has been paid to pollutants such as ozone,
carbon monoxide, and nitrogen oxide that reduce the quality of the air we
breathe outdoors. However, indoor air pollution can affect respiratory health
as well. Synthetic or plastic building materials can emit gas; spores, animal
dander, mites, pollen, plaster, bacteria, and viruses can be present in
household dust; and cigarette smoke can add carbon monoxide and
cadmium to indoor air. Conscious choices to minimize exposure to air
pollution in the places where we reside, work, and play can help alleviate
some of the stress to our respiratory systems. Furthermore, the quality of
indoor air can be improved by
Installing and maintaining air filters in heating and air-conditioning

systems
Vacuuming regularly (preferably using a central vacuum system or a
water-trap vacuum that prevents dust from returning to the room)
Damp-dusting furnishings
Discouraging cigarette smoking
Opening windows to air out rooms
Maintaining green houseplants to help detoxify the air
Nurses should assist older adults in identifying and reducing sources of

indoor pollutants. Housecleaning hints may be shared (e.g., dusting with a
damp cloth, airing out blankets, and removing unnecessary stored paper and
cloth objects); in some situations, helping older adults locate housecleaning
services can prove beneficial to improving their respiratory health.
POINT TO PONDER
What sources of air pollution are you able to identify in your home and
work environments? What can you do to correct them?
Finally, often overlooked in the prevention of respiratory problems is

the significance of a healthy oral cavity. Infections of the oral cavity can
lead to respiratory infections or can decrease appetite and facilitate a
generally poor health status. As noted, teeth can break or dislodge, leading
to lung abscesses, infections, and aspirated tooth fragments. Respiratory
infections may decline when loose or diseased teeth are removed.
Some considerations for promoting effective breathing can be found in
the Nursing Problem Highlight 16-1.
REDUCED BREATHING CAPACITY
Overview
In late life, there is a high prevalence of conditions that limit the ability to
adequately inflate the lungs or rid them of sufficient amounts of carbon
dioxide. Signs such as confusion, dyspnea, shortness of breath, abnormal
arterial blood gases, cyanosis, pursed lip breathing, retraction of
respiratory muscles during breathing, and shallow respirations could be
associated with this diagnosis.
Weakness, fatigue, pain, paralysis, immobility, altered mental status, and
respiratory or musculoskeletal disease
Goal
The patient displays an effective breathing pattern and possesses normal
arterial blood gases.
Interventions
Instruct the patient in breathing exercises (see Fig. 16-1).
Control symptoms (e.g., pain) that could threaten effective
respirations.
Raise the head of the bed at least 30 degrees when the patient is lying
down, unless contraindicated.
Instruct the patient to turn, cough, and deep breathe at least once
every 2 hours.
Monitor rate, depth, and rhythm of respirations; coloring; coughing
pattern; blood gases; and mental status.
SELECTED RESPIRATORY
CONDITIONS

Chronic obstructive pulmonary disease (COPD) represents a group of
diseases including a form of asthma, chronic bronchitis, and emphysema.
The incidence of COPD is higher in women and in smokers.
Asthma
Some older persons are affected with asthma throughout their lives; others
develop it during old age. Although most people with asthma can
effectively control it and have normal lung function between attacks, there
is a small percentage who suffer symptoms that are difficult to control,
known as severe or refractory asthma (Reihman, Holguin, & Sharma,
2020). It is the severe or refractory form of asthma that is considered a
COPD.
The symptoms and management of asthma in older adulthood do not
differ much from those in other age groups. Because of the added stress that
asthma places on the heart, however, older asthmatics have a high risk of
developing complications such as bronchiectasis and cardiac problems.
They also have higher rates of mortality from this condition. The nurse
should help detect causative factors (e.g., emotions, mouth breathing, and
chronic respiratory infections) and educate the patient regarding early
recognition of and prompt attention to an asthma attack when it does occur.
Careful assessment of the older asthmatic patient’s use of aerosol
nebulizers is advisable. Due to the difficulty some older people have in
properly using inhalers, a spacer or holding chamber may be helpful to
allow the inhalant medication to penetrate deep into the lungs. These
systems consist of aerochambers that trap the medication or holding
chambers that collapse and inflate during inhalation and expiration. Specific
instructions are provided with each system. It is beneficial for the nurse to
review the use of these devices as part of every assessment of patients who
use them.
Precautions to avoid adverse drug effects are important. Overuse of
sympathomimetic bronchodilating nebulizers creates a risk of cardiac
arrhythmias leading to sudden death. Cromolyn sodium is one of the least
toxic respiratory drugs that can be used, although several weeks of therapy
may be necessary for benefits to be realized. Some of the new steroid
inhalants are effective and carry a lower risk of systemic absorption and
adverse reactions than do older steroids.
Chronic Bronchitis
Many older persons demonstrate a persistent, productive cough; wheezing;
recurrent respiratory infections; and shortness of breath caused by chronic
bronchitis. These symptoms may develop gradually, sometimes taking years
for the full impact of the disease to be realized, when, because of
bronchospasm, patients notice increased difficulty breathing in cold and
damp weather. The condition results from recurrent inflammation and
increased mucus production in the bronchial tubes, which, over time,
produce blockage and scarring that restrict airflow. Individuals with chronic
bronchitis experience more frequent respiratory infections and greater
difficulty managing them. Episodes of hypoxia begin to occur because
mucus obstructs the bronchial tree and causes carbon dioxide retention. As
the disease progresses, emphysema may develop, and death may occur from
obstruction.

The most common manifestations of COPD are cough, dyspnea,
wheezing, and increased sputum production. Shortness of breath can be a
symptom of COPD, but chest pain is not a symptom.
Management of chronic bronchitis, aimed at removing bronchial

secretions and preventing obstruction of the airway, is similar for all age
groups. Older patients may need special encouragement to maintain good
fluid intake and to expectorate secretions. The nurse can be most effective
in preventing the development of chronic bronchitis by discouraging
chronic respiratory irritation, such as from smoking, and by helping older
adults prevent respiratory infections.
POINT TO PONDER
Smoking-related respiratory diseases have an impact not only on the
affected individual but also on society in terms of health care costs. What
do you think about the costs to society that result from an individual’s
personal decision to smoke? What incentives could be used by society to
discourage this behavior?
Emphysema
Emphysema occurs with increasing incidence in the older population.
Factors causing this destructive disease include chronic bronchitis, chronic
irritation from dusts or certain air pollutants, and morphologic changes in
the lungs, which include distension of the alveolar sacs, rupture of the
alveolar walls, and destruction of the alveolar capillary bed. Cigarette
smoking also plays a major role in the development of emphysema. The
symptoms are slow in onset and initially may resemble age-related changes
in the respiratory system, causing many patients to experience delayed
identification and treatment of this disease. Gradually, increased dyspnea is
experienced, which is not relieved by sitting upright as it may have been in
the past. A chronic cough develops. As more effort is required for breathing
and hypoxia occurs, fatigue, anorexia, weight loss, and weakness are
demonstrated. Recurrent respiratory infections, malnutrition, congestive
heart failure, and cardiac arrhythmias are among the more life-threatening
complications older adults can experience from emphysema.
Treatment usually includes postural drainage, bronchodilators, the
avoidance of stressful situations, and breathing exercises, which are an
important part of patient education. Cigarette smoking should definitely be
stopped. The older patient may have insufficient energy to consume
adequate food and fluid; nurses need to assess for this and arrange for
dietary interventions that can facilitate intake (e.g., frequent small feedings
and high-protein supplements). If oxygen is used, it must be done with
extreme caution and close supervision. It must be remembered that for these
patients, a low oxygen level rather than a high carbon dioxide level
stimulates respiration. The older patient with emphysema is a high-risk
candidate for the development of carbon dioxide narcosis. Respiratory
infections should be prevented, and any that do occur, regardless of how
minor they may seem, should be promptly reported to the physician.
Sedatives, hypnotics, and narcotics may be contraindicated because the
patient will be more sensitive to these drugs. It may be useful to consult
with patients’ physicians regarding the possibility of lung volume reduction
surgery (a procedure in which the most severely diseased portions of the
lung are removed to allow remaining tissues and respiratory muscles to
work better).
Patients with emphysema need a great deal of education and support to
be able to manage this disease. Adjusting to the presence of a serious
chronic disease requiring special care or even a lifestyle change may be
difficult. The patient must learn to pace activities, avoid extremely cold
weather, administer medications correctly, and recognize symptoms of
infection. NURSING CARE PLAN 16-1 outlines a sample care plan for the
patient with COPD.

The Older Adult With Chronic Obstructive Pulmonary
Disease
Nursing Problems: Poor gas exchange related to chronic tissue
hypoxia; potential for infection related to pooling of secretions in the
lungs
FIGURE 16-2 Immobile states increase the risk of
pneumonia in older adults.
Nursing Problem: Easily fatigued related to chronic hypoxia

KEY CONCEPT
Chronic bronchitis, emphysema, and a form of asthma are grouped in the
category of chronic obstructive pulmonary disease because of their
common outcome of obstructing airflow.
Unfolding Patient Stories: Henry Williams •

Part 1
Henry Williams, age 69, is a retired rail

system engineer who has chronic obstructive pulmonary disease (COPD),
which is exacerbated by frequent respiratory infections. In addition to
COPD, what age-related alterations and risk factors can affect his
respiratory function? What nursing interventions and education can
promote Henry’s respiratory wellness? What resources could the nurse
suggest to Henry to improve self-management of COPD? (Henry
Williams’ story continues in Chapter 34.)
Care for Henry and other patients in a realistic virtual environment:
Pneumonia
Pneumonia, especially bronchopneumonia, is common in older adults and is
one of the leading causes of death in this age group. Several factors
contribute to its high incidence:
Poor chest expansion and more shallow breathing due to age-related

changes to the respiratory system
High prevalence of respiratory diseases that promote mucus formation
and bronchial obstruction
Lowered resistance to infection
Reduced sensitivity of pharyngeal reflexes, which promotes aspiration
of foreign material
High incidence of conditions that cause reduced mobility and
debilitation (Fig. 16-2)
Greater likelihood for older adults to be hospitalized or
institutionalized and to develop nosocomial pneumonia than for
younger persons
Pneumococcal pneumonia caused by Streptococcus pneumoniae is the

most common type of pneumonia in older adults. Other pneumonias are
caused by gram-negative bacilli (Klebsiella pneumoniae), Legionella
pneumophila, anaerobic bacteria, and influenza (Haemophilus influenzae).
The signs and symptoms of pneumonia may be altered in older persons,
and serious pneumonia may exist without symptoms being evident.
Pleuritic pain, for instance, may not be as severe as that described by
younger patients. Differences in body temperature may cause minimal or no
fever. Symptoms may include a slight cough, fatigue, and rapid respiration.
Confusion, restlessness, and behavioral changes may occur as a result of
cerebral hypoxia. Nursing care for the older patient with pneumonia is
similar to that used for the younger patient. Close observation for subtle
changes is especially important. The older patient can also develop the
complication of paralytic ileus, which can be prevented by mobility.
COMMUNICATION TIP
Due to the fact that the diagnosis of pneumonia in older adults can be
delayed because of an atypical presentation of symptoms, it is
beneficial to reinforce with older adults and their caregivers the
importance of identifying and reporting symptoms early. Describing
symptoms on a level that is appropriate for the individual can facilitate
this. For example, instead of using the term productive cough, use
coughing up phlegm or bringing up mucus; heaviness or tightness of
the chest can be used as descriptors of chest pain. Likewise, because
many people think of fever as a high temperature (e.g., 101°F) and
many older individuals demonstrate fever at lower temperatures due to
their lower normal body temperatures, descriptions such as having a
warm feeling and sweating may be useful to offer.
KEY CONCEPT
Productive cough, fever, and chest pain may be atypical in older adults
because of age-related changes, which may cause a delayed diagnosis of
pneumonia.
Although their effectiveness continues to be debated, pneumococcal

vaccines are recommended for persons over 65 years of age. The vaccine
should not be administered during a febrile illness. Concurrent
administration with influenza and some other vaccines is acceptable,
provided that different injection sites are used. Common side effects are
local redness, fever, myalgia, and malaise. Some individuals may
experience arthritic flare-ups and, more rarely, paresthesias and other
neuropathies. The Centers for Disease Control and Prevention (CDC)
recommends a pneumococcal vaccination and a one-time booster after 5
years if the person was under 65 years of age when the initial vaccination
was administered. Nurses should be sure to document the administration of
the vaccine, along with the name of the manufacturer, lot number, and
expiration date. The CDC also advises that if there is doubt whether the
vaccine has already been given, it is best to administer the vaccine rather
than risk pneumonia.
Influenza
Most deaths from influenza occur in the older population, emphasizing the
seriousness of this infection to older adults. Of the two subtypes of
influenza, influenza A is the most frequent cause of serious illness and
death in older adults; influenza B is less severe, although it can produce
serious problems for older adults. Age-related changes, including an
impaired immune response to the virus, cause older persons to be highly
susceptible to influenza. Typically, influenza causes fever (although not as
high as in younger adults), myalgia, sore throat, and nonproductive cough.
It is not unusual for older adults, particularly those who are frail, to present
atypical symptoms, which can delay its recognition. Once it attacks,
influenza destroys ciliated epithelial cells of the respiratory tract and
depresses mucociliary clearance. Secondary bacterial infections and other
complications increase the risk of older adults dying as a result of influenza.
Patients with chronic respiratory, cardiac, or metabolic disease are at
particularly high risk for developing secondary bacterial pneumonia.
Nonpulmonary complications can include myositis, pericarditis, Guillain-
Barré syndrome, encephalitis, and a temporary loss of smell or taste.
The serious consequences of influenza for older adults necessitate
preventive measures. Because influenza is acquired through inhalation of
infected droplets, reducing contact with persons with known or suspected
influenza is important. Prevention also can be achieved by annual influenza
vaccination, which is recommended for persons over age 65 years.
Although older persons have lower antibody titers after vaccination than do
younger adults, vaccination can prevent severe complications associated
with influenza, even if it does not prevent the disease itself. Approximately
2 weeks are needed for an antibody response to the vaccine; therefore,
administration of the vaccine in October is recommended so that immunity
is present before the flu season peaks. Because the flu season can last
through February, vaccinations for older adults can be administered after
October. Immunity gradually declines in the months following vaccination,
so annual revaccination is needed. The vaccine is contraindicated in persons
with febrile conditions and those with a history of Guillain-Barré syndrome.
Persons with egg allergies can receive an influenza vaccine; people with
severe egg allergies can receive the vaccine but should do so in a medical
setting supervised by a health care provider (Centers for Disease Control
and Prevention, 2019). The blood level of carbamazepine, phenobarbital,
phenytoin, theophylline, and warfarin can rise within 1 to 4 weeks after
vaccination; therefore, patients using these drugs need to be closely
monitored for toxic reactions. It is advisable for persons who work with
older adults to be immunized.
Lung Cancer
Most lung cancer now occurs in patients older than 65 years. The
generational patterns in smoking prevalence are a large factor responsible
for this, although improved diagnostic tools and greater numbers of people
surviving to advanced years certainly play a role in the high incidence of
lung cancer in older adults. Lung cancer occurs more frequently in men,
although the rate among women is rising. The incidence and mortality rate
from lung cancer are highest among black males, followed (in order of
incidence) by white males, white females, and black females; among
American Indian/Alaska Native, Asian/Pacific Islander, and Hispanic
individuals, the rate of lung cancer was higher in males than in their female
counterparts (U.S. Cancer Statistics Working Group, 2020). Cigarette
smokers have twice the incidence as nonsmokers. A high incidence also
occurs among individuals who are chronically exposed to agents such as
asbestos, coal gas, radioactive dusts, and chromates. This emphasizes the
importance of obtaining thorough information regarding a patient’s
occupational history as part of the nursing assessment. Although conclusive
evidence is unavailable, some association has been reported between the
presence of lung scars, such as those resulting from tuberculosis and
pneumonitis, and lung cancer.
KEY CONCEPT
Chronic exposure to cigarette smoke, asbestos, coal gas, radon gas, and
air pollutants contributes to the development of lung cancer.
The individual may have lung cancer long before any symptoms
develop. Thus, people at high risk should be screened regularly. Dyspnea,
coughing, chest pain, fatigue, anorexia, wheezing, and recurrent upper
respiratory infections are part of the symptoms seen as the disease
progresses. Diagnosis is confirmed through chest roentgenogram, sputum
cytology, bronchoscopy, and biopsy. Treatment may consist of surgery,
chemotherapy, or radiotherapy, requiring the same type of nursing care as
that for patients of any age with this diagnosis.
Lung Abscess
A lung abscess may result from pneumonia, tuberculosis, a malignancy, or
trauma to the lung. Aspiration of foreign material can also cause a lung
abscess; this may be a particular risk to aged persons who have decreased
pharyngeal reflexes. Symptoms, which resemble those of many other
respiratory problems, include anorexia, weight loss, fatigue, temperature
elevation, and a chronic cough. Sputum production may occur, but this is
not always demonstrated in older persons.
Diagnosis and management are the same as that for other age groups.
Modifications for postural drainage, an important component of the
treatment, are discussed later in this chapter. Because protein can be lost
through the sputum, a high-protein, high-calorie diet should be encouraged
to maintain and improve the nutritional status of the older patient.
GENERAL NURSING
CONSIDERATIONS FOR
RESPIRATORY CONDITIONS
Older adults should be advised to seek medical attention promptly if any
sign of a respiratory infection develops. Frequently, older people do not
experience chest pain associated with pneumonia to the same degree as
younger adults do, and their normally lower body temperature can cause an
atypical appearance of fever (i.e., at lower levels than would occur for
younger persons). Thus, by the time symptoms are visible to others,
pneumonia can be in an advanced stage.
The nurse should teach older persons to report changes in the character
of sputum, which could be associated with certain disease processes. For
example, the sputum is tenacious, translucent, and grayish white with
COPD; it is purulent and foul smelling with a lung abscess or
bronchiectasis, and it is red and frothy with pulmonary edema and left-sided
heart failure.
Once respiratory diseases have developed, close monitoring of the patient’s
status is required to minimize disability and prevent mortality. Close
nursing observation can prevent and detect respiratory complications and
should include checking the following:
Respiratory rate and volume

Pulse (e.g., a sudden increase can indicate hypoxia)
Blood pressure (e.g., elevations can occur with chronic hypoxia)
Temperature (e.g., not only to detect infection but also to prevent stress
on the cardiovascular and respiratory systems as they attempt to meet
the body’s increased oxygen demands imposed by an elevated
temperature)
Neck veins (e.g., for distension)
Patency of airway
Coughing (e.g., frequency, depth, and productivity)
Quality of secretions
Mental status
Falls can be another unwanted outcome of having a respiratory disease.

People with COPD have a higher incidence of balance impairments and
greater risk for falls (McLay et al., 2020). Advising patients about this risk
and educating them about actions that can prevent falls are a beneficial part
of their care plan.
ENSURING SAFE OXYGEN
ADMINISTRATION
Oxygen therapy should be used prudently to treat respiratory disorders in
older adults. COPD or chronic high levels of oxygen (from oxygen therapy)
can contribute to a person retaining a higher amount of carbon dioxide in
his or her lungs; carbon dioxide retention increases the risk of developing
the serious complication of carbon dioxide narcosis during oxygen therapy
(Fig. 16-3). The nurse should monitor blood gases and observe the patient
for symptoms of carbon dioxide narcosis, which include confusion, muscle
twitching, visual defects, profuse perspiration, hypotension, progressive
degrees of circulatory failure, and cerebral depression, which may be
displayed as increased sleeping or a deep comatose state.
FIGURE 16-3 Oxygen must be administered to older
people carefully. Chronic high levels of oxygen can
depress the respiratory stimulus in the brain, thereby
reducing respiration and promoting carbon dioxide
retention.
Because inappropriate oxygen administration can have serious

consequences for older persons, nurses must strictly adhere to proper
procedures when it is used. The nurse should check the gauge frequently to
ensure that it is set at the prescribed level and check the oxygen flow for
any interruption or blockage from an empty tank, kinked tubing, or other
problems. The nurse should evaluate and recommend the method of
administration that will be most effective for the individual patient. Older
patients who breathe by mouth or have poor control in keeping their lips
sealed most of the time may not receive the full benefit of a nasal cannula.
An emaciated person whose facial structure does not allow for a tight seal
of a face mask may lose a significant portion of oxygen through leakage. A
patient who is insecure and anxious inside an oxygen tent may spend
oxygen for emotional stress and not gain full therapeutic benefit. The
patient’s nasal passages should be regularly cleaned to maintain patency.
Indications of insufficient oxygenation must be closely monitored; some
older persons will not become cyanotic when hypoxic, so the nurse must
evaluate other signs.
With increasing numbers of patients being discharged from hospitals on
oxygen for home use and with the realization that many older people lack
capabilities, knowledge, and caregiver support, realistic appraisals of the
patient’s ability to use home oxygen safely are crucial. The patient should
have information reinforced and receive supervision through home health
agencies or other community resources until the patient or caregiver is
comfortable and competent with this treatment. The home environment
needs to be evaluated for safety. Consideration must be given to the impact
of oxygen on the patient and family’s total lifestyle; whether home oxygen
results in the family having a new lease on life or becoming prisoners in
their home can be influenced by the assistance and support they receive.
Postural drainage (see Fig. 16-4) is often prescribed for removing bronchial
secretions in certain respiratory conditions. The basic steps for this
procedure are the same as those for other adults, with some slight
modifications. If aerosol medications are prescribed, the nurse administers
them before the postural drainage procedure. The position for postural
drainage depends on the individual patient and on the portion of the lung
involved. The older patient needs to change positions slowly and be
allowed a few minutes to rest between position changes to adjust to the new
position. The usual last position for postural drainage—lying face down
across the bed with the head at floor level—may be stressful for the older
person and have adverse effects. The nurse can consult with the physician
regarding the advisability of this position and possible alterations to meet
the needs of the individual patient. If this position is used, it is beneficial to
assess the patient’s tolerance and modify positioning accordingly as needed.
Cupping and vibration facilitate drainage of secretions; however, old tissues
and bones are more fragile and may be injured more easily. The procedure
should be discontinued immediately if dyspnea, palpitation, chest pain,
diaphoresis, apprehension, or any other sign of distress occurs. Thorough
oral hygiene and a period of rest should follow postural drainage.
Documentation of the tolerance of the procedure and the amount and
characteristic of the mucus drained is essential.
FIGURE 16-4 Postural drainage. Shown are four
positions that use the force of gravity to assist the drainage
of secretions from the smaller bronchial airways into the
main bronchi and trachea to enable the patient to cough
them up. (Reprinted from Taylor, C., Lillis, C., & Lynn, P.
(2015). Fundamentals of nursing (8th ed., Fig. 38.12).
Philadelphia, PA: Wolters Kluwer, with permission.)

Coughing to remove secretions is important in the management of
respiratory problems; however, nonproductive coughing may be a useless
expenditure of energy and stressful to the older patient. Various measures
can be used to promote productive coughing. Hard candy and other sweets
increase secretions, thereby helping to make the cough productive. The
breathing exercises discussed earlier can also be beneficial. A variety of
humidifiers can be obtained without prescription for home use; the nurse
needs to teach the patient the correct, safe use of such an apparatus.
Expectorants also may be prescribed to loosen secretions and make
coughing more productive. A basic, although extremely significant,
measure to reinforce is good fluid intake. Patients should be advised to use
paper tissues, not cloth handkerchiefs, for sputum expectoration. Frequent
hand washing and oral hygiene are essential and have many physical and
psychological benefits.
KEY CONCEPT
Nonproductive coughing can be a useless expenditure of energy and can
be stressful to an older adult.

Some herbs are believed to affect respiratory health. Mullein, gingko
extract, peppermint, plantain leaf, and slippery elm have mucus-secreting
effects and can soothe irritated respiratory linings. Lobelia, eucalyptus, and
licorice root have been used as expectorants. Aromatherapy using
eucalyptus, pine, lavender, and lemon may prove useful. Prior to
introducing any herbal remedy, the nurse must research for possible
interactions with medications the patient is using and discuss with the
physician.
CONSIDER THIS CASE

Seventy-nine-year-old Mr. B, who has
chronic obstructive pulmonary disease, lives at home with his 80-year-old
wife, who has Alzheimer’s disease. Mrs. B is able to ambulate and
perform activities of daily living with guidance from Mr. B; however, Mrs.
B displays poor judgment and requires close supervision. Recently, Mr. B
was hospitalized for pneumonia and discharged with home oxygen. His
wife, who stayed with a friend during Mr. B’s hospitalization, has returned
home. Mr. B desires to care for his wife at home but finds his energy
reserves are low and has difficulty tracing her steps throughout the house
while attached to his oxygen. The couple desperately wants to stay in their
home but have no family in the area and receive only limited assistance
from friends and neighbors.
THINK CRITICALLY
1. What are the risks faced by this couple and how can they be
minimized?
2. What assistance could be provided to the couple?
Hot, spicy foods (e.g., garlic, onion, and chili peppers) can have the
effect of opening air passages, whereas mucus-forming foods, such as dairy
products and processed foods, can thicken mucus and reduce the full
exchange of air.
Acupuncture, under a trained therapist, is used for the management of
asthma, emphysema, and hay fever. Acupressure is being used with some
benefit by persons with asthma, bronchitis, and emphysema. Yoga can
promote deep breathing and good oxygenation of tissues. Rolfing (a
technique using pressure applied with the fingers, knuckles, and elbows to
release fascial adhesions and realign the body into balance) and massage
can free the rib cage and improve breathing.
Growing numbers of Americans are using complementary therapies for
the prevention and management of respiratory conditions. Although the
efficacy of these methods may not be fully established, nurses should keep
an open mind; if there are no contraindications to the use of the therapy and
it is believed by the individual to be of benefit, positive outcomes could be
achieved by integrating complementary with conventional treatments.
Promoting Self-Care
Bronchodilators may be prescribed in inhaler form for the treatment of
bronchial asthma and other conditions causing bronchospasm, such as
chronic bronchitis or emphysema. Effective use of these devices depends on
the ability of the individual to manipulate the apparatus and coordinate the
spray with inhalation—areas that can be problematic for older persons with
slower responses, poorer coordination, arthritic joints, or general weakness.
Before an inhaler is prescribed, the ability of the patient to use it correctly
must be assessed. Respiratory therapists can be of assistance in
recommending devices that can assist patients in overcoming specific
obstacles to using inhalers. If the patient is able to manage the skills
required for use, instructions and precautions should be reviewed in-depth.
The patient and caregivers must understand the serious cardiac effects of
excessive use. Normally, one or two inhalations are sufficient to relieve
symptoms for 4 hours. To ensure that the inhaler does not become empty
unexpectedly and leave the person without medication when needed, the
fullness of the inhaler should be evaluated periodically by placing it in a
bowl of water. When full, the inhaler will sink; when empty, it will float—
varying levels in between indicate partial levels of fullness.
KEY CONCEPT
The effective use of inhalers requires the ability of the user to manipulate
the apparatus and coordinate the spray with inhalation—tasks that may
be difficult for some older persons.
Not long ago, patients on ventilator support were found in intensive

care units of acute hospitals. Today, growing numbers of ventilator-
dependent persons are being managed at home or in long-term care
facilities. Each ventilator has unique features, and nurses should seek the
guidance of a respiratory care specialist to ensure a thorough understanding
and correct use of the equipment. Whether in their own homes or in an
institutional setting, these patients need strong multidisciplinary support to
assist with the complex web of physical, emotional, and social care needs
they may present. Nurses can play a significant role in providing a realistic
assessment of the abilities of patients and family caregivers to manage
ventilator-related care. It makes little sense to use a ventilator to save a
patient’s life and then threaten that life by sending the person home with a
family who cannot meet care needs. Special attention also must be paid to
the quality of life of the ventilator-dependent patient; counseling, sensory
stimulation, expressive therapies, and other resources should be used.
Respiratory problems are frightening and produce anxiety. Patients with
these conditions require psychological support and reassurance, especially
during periods of dyspnea. Patients need a complete understanding of their
disease and its management to help reduce their anxiety. Repeated
encouragement may be required to assist the patient in meeting the demands
of a chronic disease. Some patients may find it necessary to spend most of
their time indoors to avoid the extremes of hot and cold weather; some may
have to learn to transport oxygen with them as they travel outside their
homes; some may need to move to a different climate for relief. These
changes in lifestyle may have a significant impact on their total lives. As
with any persons having chronic diseases, patients with respiratory
problems can benefit from being assisted to live the fullest life possible
with their conditions, rather than become prisoners to them.
Risk Factors for Depression in Patients With

Source: Yao, H., Xiao, R., Cao, P., Wang, X., Zuo, W., & Zhang, W. (2020).
World Journal of Psychiatry , 10 (4), 59–70.
The various respiratory diseases that are included within the category of
chronic obstructive pulmonary disease are common among older adults. In
caring for patients with COPD, several criti cal issues must be considered,
including actions to ensure a patent airway and sufficient respiratory
exchange. With attention to those measures that foster adequate respiration,
other issues that don’t present as critical (such as emotional state) risk being
overlooked. Unfortunately, unrecognized depression affects compliance
with medical treatment, causes more frequent visits with the primary care
provider, and increases the frequency of hospital admission.
This study aimed to identify factors in patients with COPD that placed
them at high risk for depression. The researchers reviewed the demographic
profiles, clinical data, and signs of depression of patients with COPD. Of
the 293 patients reviewed, slightly more than 22% were identified to have
depression. This was consistent with other studies that found the prevalence
of depression in patients with COPD to range from 10% to 42%. The
patients with depression were found to have lower body mass index, low
forced expiratory volume, and a high COPD assessment test score.
When patients with COPD visit their primary care provider or
pulmonologist, the focus may be on their respiratory status and
management of the disease; the provider might not inquire about the
patient’s emotional state. Nurses can play an important role in taking a
holistic approach in assessing all facets of patients’ health. Recognizing that
there is a high risk for depression among patients with COPD, nurses can
ask these patients specific questions that could reveal the presence of
depression and facilitate efforts to ensure depression or other mental health
issues are addressed.
PRACTICE REALITIES
Mrs. O’Day was discharged from the hospital, and you are scheduled to
visit her every 3 days for the next 2 weeks to assist in the care of her
abdominal incision. She has had a history of recurrent respiratory infections
and regularly uses over-the-counter antihistamines for what she has
described as “allergies.”
Upon your first home visit, you find Mr. and Mrs. O’Day, both 76 years
old, living with their six cats. The house appears dirty and cluttered, and a
strong urine odor from the pets permeates the entire home. Cat hair is on all
the upholstered furniture and carpeting.
During the entire visit, various cats climb on and off Mrs. O’Day’s lap,
and she experiences an episode of sneezing and running nose.
You ask her if she has considered that her allergy problem could be
related to her cats and she responds, “They probably have something to do
with it, but they are my babies and I’m a sucker when a stray shows up
needing a home. I couldn’t think of parting with them.” Mr. O’Day supports
his wife’s position, stating that “I’m guilty of being a cat lover too.”
How could you address the health issues related to the cats while
respecting the O’Days’ desire to have cats in their household?

1. What self-imposed and environmentally imposed risks to younger
adults can contribute to the development of respiratory conditions in
later life?
2. In what ways can age-related changes affect the development,
recognition, and management of respiratory conditions?
3. What key points would you include in an educational program for the
promotion of respiratory health in senior citizens?
4. Describe the precautions that must be taken when oxygen is
administered to older adults.

questions.
Mr. Tomlin has recently moved to this area and is seeking to affiliate
with a senior care clinic. Today he is having his initial history and
physical assessment.
Nurse’s Notes1200:
Mr. Tomlin is a 69-year-old who lives alone since the death of his
wife 2 years ago. He moved to the area to be closer to two of his three
adult children. A son and a daughter live within 20 miles of his home,
while a daughter is currently living in Spain. He retired 6 years ago from
the daily operations of a small metal plating business he owned and
operated for 38 years.
Client reports: “I need to clear my throat a lot more than I remember
needing to; I seem to usually have a stuffy nose. Client states, “I’m in
pretty good shape, but I get tired more easily than before I retired. But I
still play 9 holes of golf twice weekly with friends.”
The client is currently prescribed lisinopril 2.5 mg (P.O.) daily for
hypertension and timolol 0.25% 1 drop in each eye daily. The client
weighs 168 lbs and is 5′11″ tall.
ASSESSMENT FINDINGS:
Diagnostic laboratory results: White blood cells (WBC) 4,500/mcL,
red blood cells (RBC) 4.2 million cells/mcL, hemoglobin (Hgb)
13.8 g/dL, hematocrit (Hct) 43%.
Temperature 96.6°F (35.9°C).
Respiratory system: Respiratory rate 16 breaths per minute. A mild
nasal septal deviation is noted. Client presents with a slightly
barreled chest. Client states smoking “a few cigarettes a day since I
was in my 20s.”
Cardiovascular system: Heart rate 80 beats per minute, regular;
blood pressure 110/76 mm Hg. Several varicose veins noted in
lower extremities bilaterally.
Renal system: No remarkable results noted upon assessment. No
history of bladder or kidney infections. No current symptomology
associated with either bladder or kidney infection. Client reports
slight difficulty starting urine flow, particularly in the morning, and
getting up once or twice during the night to urinate. Client reports
slight urine leakage.
Integumentary system: Three healed scars noted on knees
(bilaterally) and one on forearm. Client reports all were experienced
“years ago while working.” Several seborrheic keratosis noted on
back and neck.
Gastrointestinal system: No remarkable results noted upon
assessment. Client reports occasional constipation managed with a
fiber-based laxative.
Musculoskeletal system: No remarkable results noted upon
assessment. Client reports, “Joints are stiff when I get up in the
morning or after I sit for a while.” Adequate hand grip strength
bilaterally.
Chapter Summary
The aging process impacts the respiratory system, resulting in a greater risk
for full air exchange to be compromised, vital capacity to be reduced,
secretions to be expelled less effectively, and respiratory infections to
develop very easily. These risks can be decreased by the regular
performance of deep breathing exercises, avoidance or discontinuation of
smoking, physical activity, protection from exposure to air pollutants, and
promotion of good oral health.
When assessing older adults, attention should be paid to signs that
could be associated with respiratory problems, such as a ruddy pink
complexion, blue or gray discoloration of the skin, increased
anteroposterior chest diameter, reduced or asymmetrical expansion of the
chest during respirations, abnormal breath sounds during auscultation, the
lack of resonance during percussion of the lungs, coughing, and
expectoration of large amounts of, and/or discolored, mucus. The interview
should include questions about smoking history and respiratory problems
that are experienced.
Because symptoms of respiratory conditions can be altered in older
adults, nurses need to make special efforts to identify and ask about signs
and symptoms. Once respiratory diseases have developed, close monitoring
of the patient’s status is required to minimize disability and prevent
mortality.
Although beneficial in the treatment of respiratory disorders, oxygen
therapy must be monitored carefully due to the risk for carbon dioxide
narcosis. Modifications to postural drainage may be necessary due to the
possibility of older adults becoming exhausted during the procedure and not
being able to tolerate some of the positions. The seriousness of the
symptoms and their impact on the ability to perform routine activities
requires that patients be provided education, monitoring, and support to
effectively manage respiratory conditions.
Online Resources
American Lung Association
https://www.lung.org
Asthma and Allergy Foundation of America
https://www.aafa.org
National Heart, Lung, and Blood Institute Information Center
https://www.nhlbi.nih.gov
Office on Smoking and Health, Centers for Disease Control and
Prevention
https://www.cdc.gov/tobacco
References
Centers for Disease Control and Prevention. (2019). Who should and should not get a flu vaccine.
Retrieved July 8, 2020 from https://www.cdc.gov/flu/prevent/whoshouldvax.htm
McLay, R., Kirkwood, R. N., Kuspinar, A., et al. (2020). Validity of balance and mobility screening
tests for assessing fall risk in COPD. Chronic Respiratory Disease, May 11, 2020. Retrieved
July 1, 2020 from https://journals.sagepub.com/doi/10.1177/1479973120922538
Reihman, A. E., Holguin, F., & Sharma, S. (2020). Management of severe asthma beyond the
guidelines. Current Allergy and Asthma Reports , 20 (9), 47.
U.S. Cancer Statistics Working Group. (2020). U.S. Cancer Statistics Data Visualizations Tool, based
on 2019 submission data (1999–2017): U.S. Department of Health and Human Services,
Centers for Disease Control and Prevention and National Cancer Institute. Retrieved from
www.cdc.gov/cancer/dataviz
CHAPTER 17
Circulation
Chapter Outline
Effects of Aging on Cardiovascular Health
Cardiovascular Health Promotion
Proper Nutrition
Adequate Exercise
Stress Management
Cardiovascular Disease and Women
Selected Cardiovascular Conditions
Hypertension
Hypotension
Pulmonary Emboli
Hyperlipidemia
Arrhythmias
General Nursing Considerations for Cardiovascular Conditions
Prevention
Providing Foot Care
Managing Problems Associated With Peripheral Vascular Disease
Promoting Normality
LEARNING OBJECTIVES
1. Describe the effects of aging on cardiovascular health and circulation.

2. List factors that promote cardiovascular health.
3. Identify unique features of common cardiovascular diseases in older
adults.
4. Describe nursing actions to assist patients with cardiovascular
conditions.
TERMS TO KNOW
Arrhythmiaabnormal heart rate or rhythm
Atherosclerosishardening and narrowing of arteries due to plaque buildup
in vessel walls
Homans’ signpain when the affected leg is dorsiflexed, usually associated
with deep phlebitis of the leg
Hypertensionconsistent blood pressure reading of ≥130 systolic and/or
≥90 diastolic
Physical deconditioningdecline in cardiovascular function due to
physical inactivity
Postural (orthostatic) hypotensiondecline in systolic blood pressure of
20 mm Hg or more after rising and standing for 1 minute
Improved technology for early diagnosis and treatment, along with

increased public awareness of the importance of proper nutrition, exercise,
and smoking cessation, has resulted in a decline in heart disease in the
population as a whole. It is anticipated that future generations will
experience fewer deaths and disabilities associated with cardiovascular
diseases. Unfortunately, today’s older population carries the insults of many
years of inadequate preventive, diagnostic, and treatment practices, which
cause them to experience cardiovascular disease as the major reason of
disability and death. These compound some of the effects that aging has on
the cardiovascular system. With the high prevalence of cardiovascular
conditions in older adults, it is crucial that actions be planned to prevent and
address some of the potential nursing problems related to circulation.
EFFECTS OF AGING ON
CARDIOVASCULAR HEALTH
With age, heart valves increase in thickness and rigidity due to sclerosis and
fibrosis. The aorta becomes dilated, a slight ventricular hypertrophy
develops, and there is thickening of the left ventricular wall. Myocardial
muscle is less efficient and loses some of its contractile strength, causing a
reduction in cardiac output when the demands on the heart are increased.
More time is required for the cycle of diastolic filling and systolic emptying
to be completed. Calcification and reduced elasticity of vessels occur, and
older hearts are less sensitive to baroreceptor regulation of blood pressure.
These changes typically are gradual and become most apparent when the
older adult is faced with an unusual physiological stress, such as heightened
activity or an infection.
Good tissue health depends on adequate tissue perfusion (i.e.,
circulation to and from a body part). To ensure good tissue perfusion,
arterial blood pressure must remain within a normal range. Unfortunately,
older adults are more likely to suffer from conditions that can alter tissue
perfusion, such as the following:
Cardiovascular disease: arteriosclerotic heart disease, hypertension,

congestive heart failure (CHF), and varicosities
Diseases: diabetes mellitus, cancer, and renal failure
Blood dyscrasias: anemia, thrombus, and transfusion reactions
Hypotension: arising from anaphylactic shock, hypovolemia,
hypoglycemia, hyperglycemia, and orthostatic hypotension
Medication side effects: antihypertensives, vasodilators, diuretics, and
antipsychotics
Other conditions: edema, inflammation, prolonged immobility,
hypothermia, and malnutrition
Table 17-1 identifies potential nursing problems associated with age-

related risks to circulation. The nurse can assess the adequacy of tissue
circulation in older adults by reviewing the individual’s health history,
evaluating vital signs, inspecting the body, and noting signs or symptoms.
Box 17-1 lists indications of ineffective tissue perfusion.
TABLE 17-1 Aging and Risks to Adequate Circulation
BOX 17-1 Indications of Ineffective Tissue

Perfusion
Hypotension
Tachycardia, decreased pulse quality
Claudication
Edema
Loss of hair on extremities
Tissue necrosis, stasis ulcers
Dyspnea, increased respirations
Pallor, coolness of skin
Cyanosis
Decreased urinary output
Delirium (altered cognition and level of consciousness)
Restlessness
Memory disturbance
CARDIOVASCULAR HEALTH
PROMOTION
Many of the alterations in the cardiovascular system can be modified by
lifestyle and diet; therefore, the prevention of cardiovascular problems in all
age groups is an important goal for all nurses to consider. By teaching the
young and old to identify and lower risk factors related to cardiovascular
disease, nurses promote optimum health and function. Important practices
to reinforce include eating properly, getting adequate exercise, avoiding
cigarette smoke, managing stress, and using proactive interventions when
appropriate.
Proper Nutrition
A diet that provides all daily requirements, maintains weight within an ideal
range for height and age, and controls cholesterol intake is beneficial. Box
17-2 lists some general dietary guidelines for reducing the risk of
cardiovascular disease. Some nutritional supplements can also help
cardiovascular health (Box 17-3).
BOX 17-2 Dietary Guidelines for Reducing the

Risk of Cardiovascular Disease
Reduce the intake of fried foods, animal fats, and partially
hydrogenated fats. Beware of fast foods, which tend to be high in
fat and calories.
Increase the intake of complex carbohydrates and fiber. Use
unrefined whole grain products, such as whole wheat, oats and
oatmeal, rye, barley, corn, popcorn, brown rice, wild rice,
buckwheat, bulgur (cracked wheat), millet, quinoa, and sorghum.
Maintain caloric intake between ideal ranges. Reduce consumption
of nutrient-poor foods.
Use monounsaturated oils (e.g., canola oil, cold-pressed olive oil)
and omega-6 oils (e.g., black currant oil, evening primrose oil).
Eat fish rich in omega-3 fatty acids (e.g., salmon, trout, and herring)
at least twice weekly.
Reduce intake of red meat, sugar, and highly processed foods.
Limit alcoholic beverages.
BOX 17-3 Nutritional Supplements for
Cardiovascular Health a
Vitamin B 6 : effective in preventing homocysteine-induced
oxidation of cholesterol, which can aid in preventing heart attacks
and strokes
Vitamin B 12 : helps form red blood cells, can decrease
homocysteine levels
Vitamin C: helps prevent the formation of oxysterols, maintains
integrity of arterial walls
Selenium: reduces platelet aggregation
Magnesium: aids in dilating arteries and facilitating circulation,
may prevent calcification of vessels, lowers total cholesterol, raises
HDL cholesterol, inhibits platelet aggregation
Calcium: may decrease total cholesterol and inhibit platelet
aggregation
Garlic: slightly reduces blood pressure, low-density lipoprotein
concentrations, and total cholesterol levels
Chromium: lowers total cholesterol and triglycerides (particularly
when combined with niacin), raises HDL cholesterol
Potassium: can aid in reducing reliance on antihypertensives and
diuretics
Fish oil: reduces triglycerides, reduces deaths from coronary artery
disease, lowers blood pressure
Coenzyme Q10 (CoQ10): helps to lower blood pressure, protects
heart muscle
Omega-3 Fatty Acids: promotes proper cardiac function, lowers
production of triglycerides
a It is preferable to get necessary vitamins and minerals from the
diet, not through supplements. Food has many antioxidants, minerals,
flavonoids, and other nutrients that are not provided through
supplements. In addition, obtaining vitamins and minerals through food
rather than supplements reduces the risk of consuming excess levels,
which can be dangerous.
More than a decade ago, Dr. Dean Ornish promoted a diet that has been
shown to be effective not only in preventing but also in reversing heart
disease (Ness, 2019; Ornish, 2008). Dr. Ornish’s dietary program for
reversing heart disease consists of the following:
Less than 10% of calories from fat and very little of those from
saturated fat
High fiber intake
Exclusion of all oils, products containing oils, and animal products,
except nonfat milk and yogurt
Allows, but does not encourage, less than 2 oz of alcohol per day
Unrestricted intake of beans, legumes, fruits, grains, and vegetables
Ornish’s Prevention Diet is intended for persons with a cholesterol level

less than 150 or a ratio of total cholesterol to HDL cholesterol of less than 3
who have no cardiac disease. It is similar to the diet for reversing heart
disease, with the exception that as much as 20% of calories can come from
fat. (In addition to dietary modifications, Dr. Ornish’s program advocates
moderate exercise, increased intimacy, stress reduction, and other healthy
practices.)
In recent years, Ornish’s diet has been criticized as being too restrictive
of fats and contributing to the rise in obesity as people consume excess
carbohydrates with the restricted fat intake. Despite the criticism and
although many people find the restrictive diet proposed by Ornish to be
difficult to follow on a long-term basis, any sustained dietary and lifestyle
modification that supports the goals of reduced fats and stimulants,
increased dietary fiber and exercise, and effective stress management
certainly will move people in the right direction.
POINT TO PONDER
Does your current diet increase your risk of cardiac disease? If so, what
factors could present obstacles to you in changing your dietary pattern to
one that is more vegetarian, and what could you do about overcoming
these obstacles?
Proper nutrition throughout life is important to prevent hyperlipidemia,
which is a significant risk factor in cardiovascular disease. In the past
several decades, much has been learned about the significant reduction in
cardiovascular and cerebrovascular incidents associated with the reduction
of cholesterol levels in middle-aged persons. Although there is insufficient
research to demonstrate the benefits in persons of advanced age, reducing
cholesterol intake is generally a positive practice. (See discussion later in
the chapter.) Lifestyle modifications to lower cholesterol can also help
people avoid the use of cholesterol medications, which, despite their
benefits, can cause side effects, such as muscle pain, weakness, fatigue,
erectile dysfunction, memory loss, and burning and tingling in the hands
and feet.
Adequate Exercise
Automobiles, elevators, modern appliances, engagement in social media,
and less physically demanding jobs lead to a more sedentary lifestyle than
may be optimally healthy. Related to this may be the practice of being
physically inactive during the week and then filling weekends with
housecleaning, yard work, and sports activities. A sensible distribution of
exercise throughout the week is advisable and is more beneficial to
cardiovascular function than are periodic spurts of activity. The lack of
physical exercise, known as physical deconditioning , can heighten many
of the age-related functional declines that aging people can experience.
Fortunately, a slower rate of decline and improved cardiovascular status has
been found in middle-aged persons who exercised regularly. Nurses can
encourage persons who dislike scheduled exercise programs to maximize
opportunities for exercise during their routine activities (e.g., using stairs
instead of an elevator, parking their car on the far end of the lot, or walking
to the local newsstand to buy a newspaper instead of having it delivered).
Thirty minutes of moderate physical activity at least 5 days per week or 20
minutes of vigorous exercise at least 3 days per week are the recommended
levels to reduce the risk of cardiovascular disease.
KEY CONCEPT
In addition to traditional aerobic, strengthening, and balance exercises,
yoga and tai chi are good ways to enhance circulation.

Although many smokers are aware of the health risks of cigarettes, breaking
the habit is quite difficult, and, for this, people need more than to be told to
stop. They require considerable support and assistance, which are often
obtainable through smoking cessation programs. Acupuncture has proved
helpful to some individuals for smoking cessation. Even if the patient has
had repeated failures in attempting to quit, the next try could be successful
and should be encouraged. In addition to avoiding cigarette smoking
themselves, nurses can instruct people to limit their exposure to the
cigarette smoke produced by others, which also can be detrimental.
Stress Management
Stress is a normal part of life. Nurses can teach people to identify the
stressors in their lives, their unique reactions to stress, and how they can
more effectively manage stress. Relaxation exercises, yoga, meditation, and
a variety of other stress-reducing activities can prove beneficial to nearly all
persons.
Gerontological nurses understand that it is much easier and more useful
to establish good health practices early in life than to change them or deal
with their outcomes in old age.
Research continues to unfold that sheds light on routines that people can
establish to promote healthy hearts. For many years, a daily low-dose
aspirin has been recommended to reduce the risk of heart attack; however,
recent studies have challenged the value of this. Low-dose aspirin has not
been shown to be effective in preventing cardiovascular disease in black
individuals (Fernandez-Jimenez, Wang, Fuster, & Blot, 2020); for women,
particularly those 70 years and older, the risk of bleeding from daily low-
dose aspirin was shown to outweigh the benefits (Shufelt & Manson, 2020).
Because ongoing research may alter the recommendations pertaining to the
use of aspirin to prevent cardiovascular events and the fact that risks and
benefits for using this preventive measure can vary among individual
patients, nurses should encourage patients to consult their medical provider
regarding the appropriateness of initiating or continuing the use of aspirin
as a preventive measure.
For individuals at risk for heart disease, undergoing C-reactive protein
(CRP) screening is another preventive measure (Box 17-4).
BOX 17-4 Importance of C-Reactive Protein

Screening
With the awareness that inflammation in the bloodstream can be a cause
of myocardial infarction, the AHA and the Centers for Disease Control
and Prevention have recommended CRP screening for persons at
moderate risk of heart disease (Ouyang, 2020). CRP is a marker of
inflammation that is a stronger predictor of cardiovascular events than
LDL cholesterol. Two measures of CRP are suggested, with the lower
value or the average being used to determine vascular risk. Because CRP
levels are stable over long periods of time, are not affected by food
intake, and demonstrate almost no circadian variation, there is no need to
obtain fasting blood samples for CRP assessment. The cost of CRP
testing is comparable to that of standard cholesterol screening and may
be quite cost-effective in terms of avoiding serious complications and
death.
Individuals with CRP levels greater than 3 mg/dL who have LDL
cholesterol less than 130 mg/dL are considered a high-risk group and are
advised to follow Adult Treatment Panel (ATP) III lifestyle
interventions. People with an elevated CRP and LDL between 130 and
160 mg/dL are at elevated global risk and should be advised to adhere
strictly to current ATP treatment guidelines. Those individuals with
elevated CRP and LDL levels greater than 160 mg/dL may need to be
placed on medications and closely monitored for compliance to their
treatment plan.
Significantly elevated levels of CRP could be related to other causes
of systemic inflammation, such as lupus or endocarditis; additional
diagnostic testing is warranted.
A comprehensive assessment of the cardiovascular system is useful not

only in identifying signs of disease but also in learning about patients’
lifestyle habits that could contribute to cardiovascular disease (Assessment
Guide 17-1). During the assessment, the nurse identifies actual and
potential problems and develops nursing problems accordingly. Table 17-2
lists nursing problems related to cardiovascular conditions.
TABLE 17-2 Nursing Problems Related to Cardiovascular

Conditions
CARDIOVASCULAR FUNCTION
Early detection of cardiac problems can be difficult because of the atypical
presentation of symptoms, the subtle nature of the progression of cardiac
disease, and the ease with which cardiac symptoms can be mistakenly
attributed to other health conditions (e.g., indigestion and arthritis).
Careful questioning and observation can yield valuable insight into
problems that have recently developed or escaped recognition.
Clues to peripheral vascular disorders often can be detected through
general contact with patients, who may comment that their feet always feel
cold and numb, that they experience burning sensations in the calf, or that
they become dizzy on rising. They may ambulate slowly, rub their legs, or
kick off their shoes. Varicosities may be noted on the legs. Such
observations can be used to introduce discussion of peripheral vascular
problems.
Assessment of the cardiovascular system can begin at the moment you see
the patient by observing indicators of cardiovascular status. Such
observations would note the following:
Generalized coloring: Note pallor, which can accompany

cardiovascular disorders.
Energy level: Note fatigue and the amount of activity that can be
tolerated.
Breathing pattern: Observe respirations while the patient ambulates,
changes position, and speaks. Acute dyspnea warrants prompt
medical attention because it can be a symptom of myocardial
infarction in older adults.
Condition of nails: Inspect the color, shape, thickness, curvature, and
markings in nail beds, which can give insight into problems. Nails
may be thick and dry in the presence of cardiovascular disease.
Check blanching; circulatory insufficiency can delay the nails’ return
to pink after blanching. Advanced cardiac disease can cause clubbing
of the nails.
Status of vessels: Inspect the vessels on the extremities, head, and
neck. Note varicosities, as well as redness on the skin above a vessel.
Hair on extremities: Hair loss can accompany poor circulation.
Edema: Swelling of the ankles and fingers is often indicative of
cardiovascular disorders.
Mental status: Inadequate cerebral circulation often manifests itself
through confusion; evaluate cognitive function and level of
consciousness.
INTERVIEW
The interview should include a review of function, signs, and symptoms.
Ask questions pertaining to the following topics.
Symptoms
Inquire regarding the presence of dizziness, light-headedness, edema, cold
extremities, palpitations, blackouts, breathing difficulties, coughing,
hemoptysis, chest pain, or unusual sensations in the chest, neck, back, or
jaws. It is helpful to use specific examples in questions: “Do you ever feel
as though there is a vise pressing against your chest?” “Have you ever
become sweaty and had trouble breathing while you felt that unusual
sensation in your chest?” “Do you find that rings and shoes become tighter
as the day goes on?” “Do you ever get the sensation of the room spinning
when you rise from lying down?” When symptoms are reported, explore
their frequency, duration, and management.
Some patients may be able to relate symptoms to vascular problems.
However, others may be unaware that signs such as light-headedness,
scaling skin, edema, or discoloration can be associated with peripheral
vascular disorders; therefore, asking specific questions is crucial. Elicit
information through questions such as the following:
“Do your arms or legs ever become cold or numb?”

“Do dark spots or sores ever develop on your legs?”
“Do your legs get painful or swollen when you walk or stand?”
“Do you ever have periods of feeling dizzy, light-headed, or
confused?”
“Does one leg ever look larger than the other?”
Changes in Function
Ask the patient if he or she has noted changes in physical or mental
function:
“Do you have difficulty or have you noticed any changes in your
ability to walk, work, or take care of yourself?”
“Do you ever have periods in which your thinking doesn’t seem
clear?”
“Have you had to restrict activities or change your lifestyle recently?”
LIFESTYLE PRACTICES
“How often do you exercise, for what length of time, and what type
of exercise do you do?”
“What is your pattern of alcohol consumption?”
“Do you consume any illegal or recreational drugs, and if so, what
type and how frequently?”
“What supplements (vitamin, herbal, and homeopathic) are you
using?”
“Do you do anything to promote health (e.g., take a daily aspirin and
follow a special diet)?”
Inspect the patient from head to toe, noting areas of irritation or
redness over a vessel, distended vessels, edema, and pallor. Blanching
of the nail beds gives information about circulation. An examination
of the extremities should include palpitation of the pulses and
temperature of the extremities and observation of hair distribution on
the legs.
Assessment of apical and radial pulses should normally reveal a pulse
that ranges between 60 and 100 beats/min. Remember that older
hearts take longer to recover from stress; thus, tachycardia may be
detected as a result of a stress that occurred several hours earlier. If
tachycardia is discovered in an older person, reassess in several
hours.
Assess blood pressure in lying, sitting, and standing positions to
determine the presence of postural hypotension (Fig. A); positional
drops greater than 20 mm Hg are significant.
Auscultate the heart to detect thrills and bruits. Palpate the point of
maximal impulse to identify displacement, which can occur with
problems such as left ventricular hypertrophy. Measure jugular
venous pressure.
Palpate pulses bilaterally for condition of the vessel wall, rate,
rhythm, quality, contour, and equality at the following sites:
Temporal pulse, the only palpable artery of the head, located
anterior to the ear, overlying the temporal bone; normally
appears tortuous.
Brachial pulse located in the groove between the biceps and
triceps; usually palpated if arterial insufficiency is suspected.
Radial pulse branching from the brachial artery, the radial artery
extends from the forearm to the wrist on the radial side and is
palpated on the flexor surface of the wrist laterally.
Ulnar pulse also branching from the brachial artery, the ulnar
artery extends from the forearm to the wrist on the ulnar side
and is palpated on the flexor surface of the wrist medially;
usually palpated if arterial insufficiency is suspected.
Femoral pulse; the femoral artery is palpated at the inguinal
ligament midway between the anterosuperior iliac spine and the
pubic tubercle.
Popliteal pulse located behind the knee; the popliteal artery is
the continuation of the femoral artery. Having the patient flex
the knee during palpitation can aid in locating this pulse.
Posterior tibial pulse palpable behind and below the medial
malleolus.
Dorsalis pedis pulse palpated at the groove between the first two
tendons on the medial side of the dorsum of the foot; this and the
posterior tibial pulse can be congenitally absent.
Rate pulses on a scale from 0 to 4:
0 = no pulse
1 = thready, easily obliterated pulse
2 = pulse difficult to palpate and easily obliterated
3 = normal pulse
4 = strong, bounding pulse, not obliterated with pressure
Often, a stick figure is used to document the quality of pulses at

different locations (Fig. B):
While assessing pulses, inspect the vessels for signs of phlebitis.
Signs could include redness, tenderness, and edema over a vein.
Sometimes, visible signs of inflammation may not be present, and the
primary indication that phlebitis exists can be tenderness of the vessel
detected through palpation. A positive Homans’ sign (i.e., pain when
the affected leg is dorsiflexed) can accompany deep phlebitis of the
leg.
Inspect the legs for discoloration, hair loss, edema, scaling skin,
pallor, lesions, and tortuous-looking veins.
Assess skin temperature by touching the skin surface in various areas.
Assure that the patient has had recent electrocardiogram and blood
screening for cholesterol and CRP (see Box 17-4).
Alterations in cerebral circulation can cause disruptions to cognitive
function; therefore, a mental status evaluation can provide useful
information about circulatory problems.
CARDIOVASCULAR DISEASE AND

WOMEN
With age, the prevalence of cardiovascular disease increases in women,
affecting more than one third of women between 45 and 54 years of age and
nearly 70% of women 65 years and older. Cardiovascular disease is the
leading cause of death for women and kills considerably more women
yearly than does breast cancer, yet it often is not seen as a significant threat
by women. Often, women miss signs of cardiovascular disease because the
symptoms are less evident than in men; this delay in seeking evaluation can
cause the disease to progress to more serious states before diagnosis and
treatment are obtained. Women of all ages need to be educated about their
risk of cardiovascular disease and measures to promote cardiovascular
health. In addition, during routine assessments, women should be asked
about symptoms associated with cardiovascular disease to aid in revealing
ignored symptoms.
SELECTED CARDIOVASCULAR
CONDITIONS
Hypertension
The incidence of hypertension increases with advancing age and is the
most prevalent cardiovascular disease of older adults, making it a problem
the gerontological nurse commonly encounters. Many older individuals
have high blood pressure arising from the vasoconstriction associated with
aging, which produces peripheral resistance. Hyperthyroidism,
parkinsonism, Paget’s disease, anemia, and thiamine deficiency can also be
responsible for hypertension.
A normal blood pressure is present when the systolic number is 120 or
below and the diastolic is 80 or below. When the systolic ranges between
120 and 129, blood pressure is considered elevated. Individuals with
systolic pressure greater than 130 and diastolic pressure greater than 80 are
considered hypertensive. The American Heart Association (2020) views
blood pressures of 130 to 139 systolic or 80 to 89 diastolic as being stage 1
hypertension and suggests lifestyle changes and antihypertensives if there is
a risk of atherosclerotic heart disease. Stage 2 hypertension occurs when
systolic blood pressure consistently is 140 or higher or diastolic is 90 or
higher; in addition to lifestyle change, antihypertensives are likely to be
prescribed. Individuals are considered in hypertensive crisis if systolic
blood pressure exceeds 180 and/or diastolic is greater than 120; individuals
with these blood pressure levels require immediate attention to reduce the
blood pressure. The nurse should carefully assess the patient’s blood
pressure by checking it several times with the person in standing, sitting,
and prone positions. Anxiety, stress, or activity before the blood pressure
check should be noted, because these factors may be responsible for a
temporary elevation. The anxiety of being examined by a physician or of
preparing for and experiencing a visit with a health care provider frequently
causes elevated blood pressure in a usually normotensive individual.
Awakening with a dull headache, impaired memory, disorientation,
confusion, epistaxis, and a slow tremor may be symptoms of hypertension.
The presence of these symptoms with an elevated blood pressure reading
usually warrants treatment. Hypertensive older patients are advised to rest,
reduce their sodium intake, and, if necessary, reduce their weight.
Aggressive antihypertensive therapy is discouraged for older persons
because of the risk of a sudden dangerous decrease in blood pressure.
Nurses should observe for signs indicating blood pressure that is too low to
meet the patient’s demands, such as dizziness, confusion, syncope,
restlessness, and drowsiness. An elevated blood urea nitrogen level may
also be present. These signs should be observed for and communicated to
the physician if they appear. In the management of the older hypertensive
person, it is a challenge to achieve a blood pressure level high enough to
provide optimum circulation yet low enough to prevent serious related
complications.
Controversy still exists as to the proper treatment of hypertension in
older patients; therefore, hypertensive older adults may receive a wide
range of therapy, rather than antihypertensive drugs alone. Although
thiazide diuretics are commonly prescribed, often for the initial treatment of
hypertension, they are not without risks. This reinforces the importance of
nurses reviewing patients’ histories to assure regular laboratory testing is
being done to detect adverse consequences. Other drugs that can be used to
treat hypertension include beta-blockers, calcium channel blockers, and
angiotensin-converting enzyme (ACE) inhibitors.
Because they have a higher risk of adverse reactions from
antihypertensive drugs, older patients should be assisted in using
nonpharmacologic measures to reduce blood pressure whenever possible.
Biofeedback, yoga, meditation, and relaxation exercises can prove effective
in reducing blood pressure (National Center for Complementary and
Integrative Health, 2018). Garlic, coenzyme Q10, probiotics, and fish oil
supplements have been shown to reduce blood pressure in hypertensive
individuals (Matsutomo, 2020). Higher whole grain intake was associated
with a reduced risk of hypertension in middle-aged and older women,
suggesting a potential role for increasing whole grain intake in the primary
prevention of hypertension and its cardiovascular complications (Kashino et
al., 2020). Some herbs have hypotensive effects, including garlic, hawthorn
berries, Rauwolfia, and periwinkle. Conversely, other herbs such as ginseng
and licorice can cause a rise in blood pressure when used regularly. The
impact of herbs on blood pressure emphasizes the need to inquire about the
use of these products during the assessment.
The DASH (Dietary Approaches to Stop Hypertension) diet has been
recommended by the National Heart, Lung, and Blood Institute (2019) as
being beneficial in reducing blood pressure. It is a diet rich in fruits,
vegetables, whole grains, and low-fat dairy foods. The DASH diet has been
viewed as having benefits for all persons, not only those with hypertension.
Hypotension
A decline in systolic blood pressure of 20 mm Hg or more after rising and
standing for 1 minute is postural or orthostatic hypotension; a similar
reduction within 1 hour of eating is postprandial hypotension. Various
studies have shown that many older adults experience problems related to
postural and postprandial hypotension due to the increased intake of
vasoactive medications and concomitant decrease in physiologic function
(Biaggioni, 2020). This can be secondary to age-related changes, such as
blunting of the baroreflex-mediated heart rate response to hypotensive and
hypertensive stimuli and the presence of diseases that affect the heart.
Postprandial hypotension can also be related to antihypertensive
medications taken before eating and a high carbohydrate intake at meals
(the effects can be prevented by drinking a caffeinated beverage after the
meal). Hypotension can have serious consequences for older persons,
including a high risk of falls, stroke, syncope, and coronary complications.
COMMUNICATION TIP
Asking about falls during the assessment process can aid in
identifying problems with postural hypotension. Likewise, in hospital
or long-term care facility settings, questions should be asked to assess
the potential of postural changes in blood pressure in individuals with
a history of falling. Due to the high prevalence of postural
hypotension, it is beneficial to discuss with older adults and their
caregivers the importance of changing positions slowly to reduce the
risk for falls that can result from this problem.
The incidence of CHF increases significantly with age and is a leading
cause of hospitalization of older adults. It is a potential complication in
older patients with arteriosclerotic heart disease; the successful treatment of
older people with myocardial infarction (MI) with thrombolytic agents
contributes to the increasing incidence. Coronary artery disease is
responsible for most cases of CHF, followed by hypertension; other risk
factors that can precipitate CHF in older adults include diabetes mellitus,
dyslipidemia, sleep-disordered breathing, albuminuria, anemia, chronic
kidney disease, use of illicit drugs, sedentary lifestyle, and psychological
stress. This problem is common in older adults because of age-related
changes, such as reduced elasticity and lumen size of vessels and rises in
blood pressure that interfere with the blood supply to the heart muscle. The
decreased cardiac reserves limit the heart’s ability to withstand effects of
disease or injury.
Symptoms of CHF in older patients include dyspnea on exertion (the
most common finding), confusion, insomnia, wandering during the night,
agitation, depression, anorexia, nausea, weakness, shortness of breath,
orthopnea, wheezing, weight gain, and bilateral ankle edema. On
auscultation, moist crackles are heard. The nurse should promptly report to
the physician the detection of any of these symptoms.
History and physical examination assist in confirming the diagnosis of
CHF. The New York Heart Association has developed four categories of
CHF that can be used in classifying the severity of the disease and guiding
treatment (NYHA allows use of this classification system without
permission):
Class 1: Cardiac disease without physical limitation

Class 2: Symptoms experienced with ordinary physical activity; slight
limitations may be evident
Class 3: Symptoms experienced with less than ordinary activities;
physical activity significantly limited
Class 4: Symptoms experienced with any activity and during rest; bed
rest may be required
Management of CHF in older adults is basically the same as in middle-
aged adults, commonly consisting of bed rest, ACE inhibitors, beta-
blockers, digitalis, diuretics, and a reduction in sodium intake. The patient
may be allowed to sit in a chair next to the bed; usually, complete bed rest is
discouraged to avoid the potential development of thrombosis and
pulmonary congestion. The nurse should assist the patient into the chair,
provide adequate support, and, while the patient is sitting, observe for signs
of fatigue and dyspnea and changes in skin color and pulse.
The presence of edema and the poor nutrition of the tissues associated
with this disease, along with the more fragile skin of the aged, all
predispose the patient to a greater risk of skin breakdown. Regular skin care
and frequent changes of positioning are essential. CHF is a frightening, and
often recurring, condition requiring a great deal of reassurance and
emotional support. NURSING CARE PLAN 17-1 offers a basic care plan
for the older adult with heart failure.

THE OLDER ADULT WITH HEART FAILURE
Nursing Problem: Reduced tolerance for activity related to decreased
cardiac output, pain, dyspnea, fatigue.
Nursing Problem: Break in skin integrity related to edema and poor
tissue nutrition.
Nursing Problem: Fluid excess related to ineffective pumping action of

heart; nutritional deficiency related to decreased appetite, dyspnea,
dietary restrictions, side effects of treatments.
Nursing Problem: Lack of knowledge related to lifestyle modifications
and caregiving needs associated with congestive heart failure.
KEY CONCEPT
The risk of skin breakdown is high in persons with CHF because of the
presence of edema and poor nutrition of the tissues. The fragility of older
skin compounds this risk.
Pulmonary Emboli
The incidence of pulmonary emboli is high in older persons, although
detection and diagnosis of it in this age group are challenging. Patients at
high risk for developing this problem are those with a fractured hip, CHF,
arrhythmias, and a history of thrombosis. Immobilization and
malnourishment, which are frequent problems in the older population, can
contribute to pulmonary emboli. Symptoms to observe include confusion,
apprehension, increasing dyspnea, slight temperature elevation,
pneumonitis, and an elevated sedimentation rate. Older patients may not
experience chest pain because of altered pain sensations, or their pain may
be attributed to other existing problems. A lung scan or angiography may be
done to confirm the diagnosis and establish the location, size, and extent of
the problem. Treatment of pulmonary emboli in older adults does not
significantly differ from that used for the young.

Coronary artery disease is the popularly used phrase for ischemic heart
disease. The prevalence of coronary artery disease increases with advanced
age, so that some form of this disease exists in most persons 70 years of age
or older.
Angina
A symptom of myocardial ischemia, the anginal syndrome presents in an
atypical pattern in older adults, making detection difficult. Pain may be
diffuse and of a less severe nature than described by younger adults. The
first indication of this problem may be a vague discomfort under the
sternum, frequently after exertion or a large meal. The type of pain
described and the relationship of the onset of pain to a meal may cause the
patient and the health professional to attribute this discomfort to
indigestion. As this condition progresses, the patient may experience
precordial pain radiating down the left arm. Other symptoms can include
coughing, syncope, sweating with exertion, and episodes of confusion.
The recurrence of anginal syndromes over many years can result in the
formation of small areas of myocardial necrosis and fibrosis. Eventually,
diffuse myocardial fibrosis occurs, leading to myocardial weakness and the
potential risk of CHF.
Nitroglycerin has been effective in preventing and treating anginal
attacks. Older persons are more likely to experience orthostatic hypotension
with nitrates resulting from loss of vasomotor and baroreceptor reactivity.
Because this drug may cause a drop in blood pressure, lower dosages may
be indicated. The nurse cautions the patient to sit or lie down after taking
the tablet to prevent fainting episodes and falls. To prevent swallowing the
tablet and thus blocking its absorption, patients should not swallow their
saliva for several minutes after sublingual administration. Long-acting
nitrates are usually not prescribed for older adults.
To prevent anginal syndromes, the nurse teaches and helps the patient to
avoid factors that may aggravate this problem, such as cold wind, emotional
stress, strenuous activity, anemia, tachycardia, arrhythmias, and
hyperthyroidism. Acupuncture has been shown to reduce the frequency and
severity of angina attacks in some individuals and is a consideration.
Because the pain associated with an MI may be similar to that of angina,
patients should be instructed to notify the physician or nurse if pain is not
relieved by nitroglycerin. Patients’ charts should include factors that
precipitate attacks, as well as the nature of the pain and its description by
the patient, the method of management, and the usual number of
nitroglycerin tablets used to alleviate the attack. Education and support in
reducing risk factors complement the plan of care.
For some patients, coronary angioplasty and stenting may be
performed. This has been shown to reduce the severity of angina and
coronary events. Studies indicate, however, that an individualized approach
is necessary, so patients should be encouraged to discuss with their
cardiologist (Almed, 2020).
Myocardial Infarction
MI is frequently seen in older persons, especially in men with a history of
hypertension and arteriosclerosis. The diagnosis of MI can be delayed or
missed in older adults because of an atypical set of symptoms and the
absence of pain. Symptoms include pain radiating to the left arm, the entire
chest, the neck, jaw, and the abdomen; numbness in arms, neck, or back;
confusion; moist, pale skin; decreased blood pressure; syncope; shortness of
breath; cough; low-grade fever; and an elevated sedimentation rate. Output
should be observed because partial or complete anuria may develop as this
problem continues. Arrhythmias may occur, progressing to fibrillation and
death, if untreated.
The trend in treating MI has been to reduce the amount of time in which
the patient is limited to bed rest and to replace complete bed rest with
allowing the patient to sit in an armchair next to the bed. The patient should
be assisted into the chair with minimal exertion by him or her. Arms should
be supported to avoid strain on the heart. Not only does this armchair
treatment help to prevent many of the complications associated with
immobility, it also prevents pooling of the blood in the pulmonary vessels,
thereby decreasing the work of the heart.
Early ambulation following an MI is encouraged. Typically, patients are
allowed out of bed within a few days of an uncomplicated MI and are
ambulating shortly thereafter. Getting out of bed early can be beneficial for
the heart (using a bedpan puts more work on the heart than using a
commode), maintains the body’s condition, and assists in the prevention of
complications associated with immobility.
Thrombolytic therapy is commonly used, and because older persons are
more susceptible to cerebral and intestinal bleeding, close nursing
observation for signs of bleeding is essential. Nurses should be alert to signs
of developing pulmonary edema and CHF, potential complications for the
geriatric patient with an MI. These and other observations, such as
persistent dyspnea, cyanosis, decreasing blood pressure, rising temperature,
and arrhythmias, reflect a problem in the patient’s recovery and should be
brought to the physician’s attention promptly.
Fitness programs have shown to be beneficial for older persons with
coronary artery disease in improving cardiac functional capacity, reducing
ischemic episodes, decreasing the risk of complications, and promoting a
sense of well-being and control over the disease. Walking, swimming, and
bicycling are excellent rhythmic, aerobic means of exercise for older adults.
Aggressive sports are not necessarily excluded but do present a greater
challenge in controlling heart rate during the exercise. All exercise sessions
should begin with a 5-minute warm-up and end with a 5- to 10-minute
cooldown of low-intensity exercises. Nurses should advise patients to
obtain a medical evaluation and exercise test before engaging in a fitness
program. Usually, a target heart rate of approximately 70% to 85% of the
maximal heart rate is recommended during exercise.
KEY CONCEPT
Fitness programs for older adults with coronary artery disease can
improve cardiac functional capacity, reduce ischemic episodes, decrease
the risk of complications, and promote a sense of well-being and control
over the condition.
Hyperlipidemia
The risk of coronary artery disease associated with elevated total
cholesterol increases with age, primarily because of increases in low-
density lipoprotein (LDL). In addition to age, older persons may have
conditions that can cause lipoprotein disorders, such as uncontrolled
diabetes, hypothyroidism, uremia, and nephrotic syndrome, or be using
corticosteroids, thiazide diuretics, and other drugs that increase the risk.
Diagnosis
Patient evaluation should include obtaining a full lipid profile rather than
just a plasma total cholesterol level. Because cholesterol values can change
from day to day, no single laboratory value should be used to classify a
patient. Triglyceride levels are sensitive to food; therefore, a definitive
screening test requires that the patient fast for 12 hours prior to testing. An
HDL level greater than 60 mg/dL is desirable; triglycerides greater than 200
mg/dL are borderline and greater than 240 mg/dL are high. An LDL less
than 100 mg/dL is recommended for people with coronary heart disease or
diabetes; a level less than 130 mg/dL is advised for persons without
coronary heart disease or diabetes who have two or more coronary risk
factors; LDL less than 160 mg/dL is desirable for persons without coronary
heart disease or diabetes who have one or no risk factors.
If secondary causes of lipoprotein disorders (e.g., diet high in saturated
fat or cholesterol, excessive alcohol intake, exogenous estrogen
supplementation, poorly controlled diabetes, uremia, and use of beta-
blockers or corticosteroids) can be ruled out, a primary or familial
lipoprotein disorder may be present. The most common familial
lipoproteinemias are transmitted as autosomal dominant traits, so children
of older adults affected by this condition need screening and counseling
regarding lifestyle practices that can prevent hypercholesterolemia.
Treatment
Dietary changes and exercise are the initial approaches to treating this
condition. The AHA’s step 1 diet is recommended for initial treatment. If
the patient is already following a diet similar to the step 1 diet, a step 2 diet
will be prescribed. The gerontological nurse should refer patients to a
nutritionist for guidance on these diets. As mentioned, the Dean Ornish diet
is more restrictive than the AHA diet and has been shown to improve LDL
levels. Box 17-5 lists some general dietary guidelines. Other lifestyle
practices that can assist include reducing weight and limiting alcohol intake.
BOX 17-5 General Dietary Guidelines for

Persons With Hyperlipoprotein Conditions
Reduce intake of egg yolks and organ meats.
Increase consumption of soluble fibers (e.g., barley, oats).
Reduce red meat intake and substitute with fish, chicken, and
turkey.
Substitute olive oil for vegetable oils.
Use skim milk and nonfat cottage cheese.
Substitute buttermilk for cream toppings.
Eat plenty of fresh fruits and vegetables.
A variety of medications can be used if diet and lifestyle modifications

alone do not bring about results. The drugs of first choice for elevated LDL
cholesterol have been the 3-hydroxy-3-methylglutaryl-coenzyme (HMG
CoA)-reductase inhibitors (e.g., atorvastatin, fluvastatin, lovastatin,
pravastatin, rosuvastatin, and simvastatin). Also known as statins, this class
of drugs has been viewed as effective for lowering LDL cholesterol levels.
Although there have been questions in the past regarding the potential
adverse events that could occur when these drugs are used, recent analysis
has concluded that the benefits far outweigh the risks (Ferri & Corsini,
2020). Bile acid sequestrants (cholestyramine and colestipol), nicotinic acid
(niacin [Nicolar]), HMG-CoA, fibrates (gemfibrozil, fenofibrate, and
clofibrate), and omega-3 fatty acids (fish oils) can also be used.
Some alternative and complementary therapies have also proven
beneficial in reducing cholesterol levels, such as water-soluble fiber (oats,
guar gum, pectin, and mixed fibers), garlic supplements, green tea, and
antioxidant vitamins A, C, and E and beta carotene.
Arrhythmias
Digitalis toxicity, hypokalemia, acute infections, hemorrhage, anginal
syndrome, and coronary insufficiency are some of the many factors that
cause an increasing incidence of arrhythmias with age. Of the causes
mentioned, digitalis toxicity is the most common. Symptoms associated
with arrhythmias include weakness, fatigue, palpitations, confusion,
dizziness, hypotension, bradycardia, and syncope.
The basic principles of treatment for arrhythmias do not vary much for
older adults. Tranquilizers, antiarrhythmic drugs, digitalis, and potassium
supplements are part of the therapy prescribed; cardioversion may also be
done. Patient education may be warranted to help the individual modify
diet, smoking, drinking, and activity patterns. The nurse should be aware
that digitalis toxicity can progress in the absence of clinical signs and with
blood levels within a normal range and that the effects can be evident even
2 weeks after the drug has been discontinued. This reinforces the
importance of nursing assessment and monitoring to detect subtle changes
and atypical symptoms. Older people have a higher mortality rate from
cardiac arrest than other segments of the population, emphasizing the need
for close nursing observations and early problem detection to prevent this
serious complication.
Atrial Fibrillation
Most persons affected by atrial fibrillation, the most common chronic
cardiac arrhythmia, are over 65 years of age. It commonly occurs in persons
with structural defects and comorbidities. In fact, most older adults who
develop atrial fibrillation have been found to have various comorbidities
such as hypertension, hyperlipidemia, or heart failure, anemia, arthritis,
diabetes mellitus, and chronic renal disease (Lee et al., 2020).
In the early stage, the individual may not experience symptoms, and the
atrial fibrillation may first be discovered upon physical examination. When
symptoms do occur, they can include palpitations, irregular pulse, shortness
of breath, chest pain, fatigue, dizziness, and delirium. At times, atrial
fibrillation comes on rapidly and resolves on its own within a short time;
this is known as paroxysmal atrial fibrillation. However, as the condition
advances, persistent atrial fibrillation, in which the episodes last longer and
don’t resolve without medical intervention, develops. In some situations,
permanent atrial fibrillation can develop, in which atrial fibrillation may be
a regular occurrence for at least 1 year and return to a normal rhythm is not
achievable. Diagnosis is made through physical examination, history, and
use of electrocardiogram, electrophysiology studies, stress tests, and
echocardiograms.
Control and prevention of atrial fibrillation are important to reducing
the risk for stroke. Treatment can include antiarrhythmics, electrical
cardioversion, and, if the condition hasn’t responded to those treatments,
catheter ablation and maze procedure (surgical ablation). In addition to
supporting the treatment plan, nurses play an important role in educating
patients about the disease, treatments, dietary and activities modifications
that may be recommended, and symptoms to promptly report (e.g.,
palpitations, edema, weight gain, shortness of breath, fatigue, signs of
bleeding).

Arteriosclerosis
Arteriosclerosis is a common problem among older persons, especially
those who have diabetes. Unlike atherosclerosis, which generally affects the
large vessels coming from the heart, arteriosclerosis most often affects the
smaller vessels farthest from the heart. Arteriography and radiography can
be used to diagnose arteriosclerosis, and oscillometric testing can assess the
arterial pulse at different levels. If surface temperature is evaluated as a
diagnostic measure, the nurse should keep the patient in a warm, stable
room temperature for at least 1 hour before testing. Treatment of
arteriosclerosis includes bed rest, warmth, Buerger-Allen exercises (Box
17-6), and vasodilators. Occasionally, a permanent vasodilation effect is
achieved by performing a sympathetic ganglionectomy.
BOX 17-6 Buerger-Allen Exercises
Instruct the patient to perform Buerger-Allen exercises by following
these steps:
1. Lie flat with legs elevated above the level of the heart until
blanching occurs (about 2 minutes; Fig. A).
2. Sit on edge of bed; lower the legs to fill the vessels and exercise feet
until the legs are pink (about 5 minutes; Fig. B).
3. Lie flat for about 5 minutes before repeating the exercises (Fig. C).
4. Repeat the entire exercise five times, or as tolerated, at three
different times during the day.
5. Assist the patient with position changes because postural
hypotension can occur. Note the patient’s tolerance and the
effectiveness of the procedure.
Special Problems Associated With Diabetes
Persons with diabetes, who have a high risk of developing peripheral
vascular problems and associated complications, commonly display
diabetes-associated neuropathies and infections that affect vessels
throughout the entire body. Arterial insufficiency can present in several
ways. Resting pain may occur as a result of intermittent claudication;
arterial pulses may be difficult to find or totally absent; and skin
discoloration, ulcerations, and gangrene may be present. Diagnostic
measures, similar to those used to determine the degree of arterial
insufficiency with other problems, include oscillometry, elevation–
dependency tests, and palpation of pulses and skin temperatures at different
sites. When surgery is possible, arteriography may be done to establish the
exact size and location of the arterial lesion. The treatment selected will
depend on the extent of the disease. Walking can promote collateral
circulation and may constitute sufficient management if intermittent
claudication is the sole problem. Analgesics can provide relief from resting
pain.
Because many of today’s older adults may have witnessed severe
disability and death among others with the disease they have known
throughout their lives, they need to be assured that improved methods of
medical and surgical management—perhaps not even developed at the time
their parents and grandparents had diabetes—increase their chances for a
full, independent life.
Aneurysms
In older adults, advanced arteriosclerosis is usually responsible for the
development of aneurysms, although they may also result from infection,
trauma, syphilis, and other factors. Some aneurysms can be seen by the
naked eye and are able to be palpated as a pulsating mass; others can only
be detected by radiography. A thrombosis can develop in the aneurysm,
leading to an arterial occlusion or rupture of the aneurysm—the most
serious complication associated with this problem.
Aneurysms of the abdominal aorta most frequently occur in older
people. Patients with a history of arteriosclerotic lesions, angina pectoris,
MI, and CHF more commonly develop aneurysms in this area. A pulsating
mass, sometimes painful, in the umbilical region is an indication of an
abdominal aortic aneurysm. Prompt correction is essential to prevent
rupture. Fewer complications and deaths result from surgical intervention
before rupture. Among the complications that older adults can develop after
surgery for this problem are hemorrhage, MI, cerebrovascular accident, and
acute renal insufficiency. The nurse should observe closely for signs of
postoperative complications.
KEY CONCEPT
Abdominal aortic aneurysms are a high risk in persons with a history of
arteriosclerotic lesions, angina pectoris, myocardial infarction, and CHF.
Aneurysms can develop in peripheral arteries, the most common site

being the popliteal artery followed by the femoral artery. Peripheral
aneurysms can usually be palpated, thus establishing the diagnosis. The
most serious complication associated with peripheral aneurysms is the
formation of a thrombus, which can occlude the vessel and cause loss of the
limb. As with abdominal aortic aneurysms, early treatment reduces the risk
of complications and death. The lesion may be resected and the portion of
the vessel removed replaced, commonly with a prosthetic material. For
certain patients, a lumbar sympathectomy can be performed. The nurse
should be aware that these patients can develop a thrombus postoperatively
and assist the patient in preventing this complication.
Varicose Veins
Varicosities, a common problem in old age, can be caused by lack of
exercise, jobs entailing a great deal of standing, and loss of vessel elasticity
and strength associated with the aging process. Varicosities in all ages can
be detected by the dilated, tortuous nature of the vein, especially the veins
of the lower extremities. The person may experience dull pain and
cramping of the legs, sometimes severe enough to interfere with sleep.
Dizziness may occur as the patient rises from a lying position because
blood is localized in the lower extremities and cerebral circulation is
reduced. The effects of the varicosities make the skin more susceptible to
trauma and infection, promoting the development of ulcerative lesions,
especially in the obese or diabetic patient (Box 17-7).
BOX 17-7 Topics to Include in Teaching the
Patient With a Leg Ulcer
Venous ulcers result from chronic deep vein insufficiency or severe
varicosities. The nurse teaches patients with venous ulcers to promote
tissue perfusion and prevent complications as follows:
Use gravity to promote circulation and reduce edema by elevating

the lower extremity when sitting and by avoiding prolonged
standing, sitting, and crossing the legs.
Prevent pressure on the ulcer by using an overbed cradle to keep
linens from touching the extremity.
Prevent constriction to circulation by avoiding tight socks or
garters.
Control pain by using an analgesic; taking an analgesic
approximately 30 minutes prior to the dressing change can reduce
some of the discomfort associated with the procedure.
Change the dressing as prescribed (if the patient is unable to
perform the procedure independently, instruct a caregiver).
Promote circulation by exercising (e.g., walking, swimming,
stationary bicycling, dorsiflexion of the feet).
KEY CONCEPT
Persons with varicose veins can experience dizziness when rising from a
lying position because blood is localized in the lower extremities and
cerebral circulation is reduced.
Treatment of varicose veins is aimed toward reducing venous stasis.

The patient elevates and rests the affected limb to promote venous return.
Exercise, particularly walking, will also enhance circulation. The nurse
should make sure that elastic stockings and bandages are properly used and
not constricting and that the patient is informed of the causes of venous
status (e.g., prolonged standing, crossing the legs, and wearing constricting
clothing) to prevent the development of complications and additional
varicosities. Ligation and stripping of the veins require the same principles
of nursing care used for other age groups undergoing this surgery.
Venous Thromboembolism
An increasing incidence of venous thromboembolism is found among older
adults. Patients who have been restricted to bed rest or have had recent
surgery or fractures of a lower extremity are high-risk candidates. Although
the veins in the calf muscles are the most frequently seen sites of this
problem, it also occurs in the inferior vena cava, iliofemoral segment, and
various superficial veins.
The symptoms and signs of venous thromboembolism depend on the
vessel involved. The nurse should be alert for edema, warmth over the
affected area, and pain in the sole of the foot. Edema may be the primary
indication of thromboembolism in the veins of the calf muscle, because
discoloration and pain are often absent in aged persons with this problem. If
the inferior vena cava is involved, bilateral swelling, aching and cyanosis of
the lower extremities, engorgement of the superficial veins, and tenderness
along the femoral veins will be present. Similar signs will appear with
involvement of the iliofemoral segment, but only on the affected extremity.
The location of the thromboembolism will dictate the treatment used.
Elastic stockings or bandages, rest, and elevation of the affected limb may
promote venous return. Analgesics may be given to relieve any associated
pain. Anticoagulants may be administered, and surgery may be performed
as well. The nurse should help the patient to avoid situations that cause
straining and to remain comfortable and well hydrated.
GENERAL NURSING
CONSIDERATIONS FOR
CARDIOVASCULAR CONDITIONS
Prevention
The high incidence and potentially disabling effects of cardiovascular
disease demand conscientious actions by gerontological nurses to
incorporate preventive measures into their planning and caregiving.
Education, counseling, coaching, and rehabilitative/restorative activities
facilitate prevention on three levels:
1. Primary: to prevent disease from developing in healthy older adults

2. Secondary: to strengthen the abilities of persons who are diagnosed
with disease to avoid complications and worsening of their conditions
and achieve maximum health and function
3. Tertiary: to maximize capabilities through rehabilitative and restorative
efforts so that the disease doesn’t create additional problems
The measures for promoting cardiovascular health described at the

beginning of this chapter are advantageous to incorporate into any health
promotion plan for older adults.

Basic diagnostic and treatment measures for cardiovascular problems of
older adults will not differ greatly from those used with younger patients,
and the same nursing measures can be applied. Because of sensory deficits,
anxiety, poor memory, or illness, the older patient may not fully
comprehend or remember the explanations given for diagnostic and
treatment measures. Full explanations with reinforcement are essential.
Patients and their families should have the opportunity to ask questions and
to discuss their concerns openly. Often procedures that seem relatively
minor to the nurse, such as frequent checks of vital signs, may be alarming
to the unprepared patient and family.
The edema associated with many cardiovascular diseases may promote skin
breakdown, especially in older people who typically have more fragile skin.
Frequent changes of position are essential. The body should be supported in
proper alignment, and dangling arms and legs off the side of a bed or chair
should be avoided. A frequent check of clothing and protective devices can
aid in detecting constriction due to increased edema. Protection, padding,
and massage of pressure points are beneficial. If the patient is to be on a
stretcher, an examining table, or an operating room table for a long time,
protective padding placed on pressure points beforehand can provide
comfort and prevent skin breakdown. When much edema is present,
excessive activity should be avoided because it will increase the circulation
of the fluid, with the toxic wastes it contains, and can subject the patient to
profound intoxication. Weight and circumferences of extremities and the
abdomen should be monitored to provide quantitative data regarding
changes in the edematous state.
Accurate observation and documentation of fluid balance are especially
important. Within any prescribed fluid restrictions, fluid intake should be
encouraged to prevent dehydration and facilitate diuresis; water is effective
for this. Fluid loss through any means should be measured; volume, color,
odor, and specific gravity of urine should be noted. Intravenous fluids must
be monitored carefully, particularly because excessive fluid infusion results
in hypervolemia and can subject older adults to the risk of CHF.
Intravenous administration of glucose solution could stimulate the increased
production of insulin, resulting in a hypoglycemic reaction if this solution is
abruptly discontinued without an adequate substitute.
Vital signs must be checked regularly, with close attention to changes.
A temperature elevation can reflect an infection or an MI. The body
temperature for older individuals may be normally lower than for younger
adults; it is important to record the patient’s normal temperature when well
to have a baseline for comparison. It is advisable to detect and correct
temperature elevations promptly because a temperature elevation increases
metabolism, thereby increasing the body’s requirements for oxygen, and
causes the heart to work harder. A decrease in temperature slows
metabolism, causing less oxygen consumption and less carbon dioxide
production and fewer respirations. A rise in blood pressure is associated
with a reduced cardiac output, vasodilation, and lower blood volume.
Hypotension can result in insufficient circulation to meet the body’s needs;
symptoms of confusion and dizziness could indicate insufficient cerebral
circulation resulting from a reduced blood pressure. Pulse changes are
significant. In addition to cardiac problems, tachycardia could indicate
hypoxia caused by an obstructed airway. Bradycardia may be associated
with digitalis toxicity.
Oxygen is frequently administered in the treatment of cardiovascular
diseases, and in older patients, it requires most careful use. The nurse
should observe the patient closely for hypoxia. Patients using a nasal
cannula may breathe primarily by mouth and reduce oxygen intake.
Although a face mask may remedy this problem, it does not guarantee
sufficient oxygen inspiration. Older patients may not demonstrate cyanosis
as the initial sign of hypoxia; instead, they may be restless, irritable, and
dyspneic. These signs also can indicate high oxygen concentrations and
consequent carbon dioxide narcosis, a particular risk to older patients
receiving oxygen therapy. Blood gas levels will provide data to reveal these
problems, and early correction is facilitated by keen nursing observation.
KEY CONCEPT
Instead of demonstrating cyanosis, older adults with hypoxia can become
restless, irritable, and dyspneic.
Anorexia may accompany cardiovascular disease, and special nursing

assistance may be necessary to help patients meet their nutritional needs.
Several smaller meals throughout the entire day rather than a few large ones
may compensate for poor appetite and reduce the work of the heart.
Favorite foods, served attractively, can be effective. Patients should be
encouraged to maintain a regular intake of glucose, the primary source of
cardiac energy. Education may be necessary regarding low-sodium, low-
cholesterol, and low-calorie diets. Therapeutic dietary modifications should
attempt to incorporate ethnic food enjoyed by patients; patients may reject a
prescribed special diet if they believe they must forfeit the foods that have
been an important component of their lives for decades. It may be necessary
to negotiate compromises; a realistic, although imperfect, diet with which
patients are satisfied is more likely to be followed than an ideal one that
patients cannot accept. The nurse should review foods included in the diets
and inform patients of the sodium, cholesterol, and caloric contents of these
items. These foods can then be categorized as those that should be eaten
“never,” “occasionally or not more than once monthly,” and “as desired.”
Patients should learn to read labels of food, beverages, and drugs for
sodium content; they must understand that carbonated drinks, certain
analgesic preparations, commercial alkalizers, and homemade baking soda
mixtures contain sodium.
KEY CONCEPT
One way to promote dietary compliance is to classify foods for the
patient as those that should “never be eaten,” “eaten occasionally,” or
“eaten as desired.”
Straining from constipation, enemas, and removal of fecal impactions

can cause vagal stimulation, a particularly dangerous situation for patients
with cardiovascular disease. Measures to prevent constipation must be an
integral part of the care plan for these patients; a stool softener may be
prescribed. If bed rest is prescribed, range-of-motion exercises should be
performed, because they will cause muscle contractions that compress
peripheral veins and thereby facilitate the return of venous blood.
Patients who are weak or who fall asleep while sitting need to have
their heads and necks supported to prevent hyperextension or hyperflexion
of the neck. All older persons, not only those with cardiovascular disease,
can suffer a reduction in cerebral blood flow from the compression of
vessels during this hyperextension or hyperflexion. Those with CHF need
good positioning and support. A semirecumbent position with pillows
supporting the entire back maintains good body alignment, promotes
comfort, and assists in reducing pulmonary congestion. Cardiac strain is
reduced by supporting the arms with pillows or armrests. Footboards help
prevent foot drop contracture; patients should be instructed in how to use
them for exercising.
If hepatic congestion develops, drugs may detoxify more slowly.
Because older adults may already have a slower rate of drug detoxification,
nurses must be acutely aware of signs indicating adverse reactions to drugs.
Digitalis toxicity particularly should be monitored and could present with a
change in mental status, nausea, vomiting, arrhythmias, and a slow pulse.
Because hypokalemia sensitizes the heart to the effects of digitalis,
prevention through proper diet and the possible use of potassium
supplements is advisable.
Because older adults experience age-related changes and a high prevalence
of health conditions that heighten their risk of altered tissue perfusion,
gerontological nurses should promote interventions that improve tissue
circulation to:
Ensure that blood pressure is maintained within an acceptable range

(usually under 130 mm Hg systolic and 80 mm Hg diastolic)
Prevent and eliminate sources of pressure on the body
Remind or assist patients to change positions frequently
Prevent pooling of blood in the extremities
Encourage physical activity
Prevent hypothermia and maintain body warmth (particularly of the
extremities)
Massage the body unless contraindicated (e.g., in the presence of deep
vein thrombosis and pressure ulcer)
Monitor drugs for the side effect of hypotension
Educate to reduce risks (e.g., avoiding excess alcohol ingestion,
cigarette smoking, use of illegal or recreational drugs, obesity, and
inactivity)
Periodically evaluate physical and mental health to identify signs and
symptoms of altered tissue perfusion
Nurses can play a significant role in preventing peripheral vascular

problems. Health education for persons of all ages should reinforce the
importance of exercise in promoting circulation; factors that can interfere
with optimal circulation, such as crossing legs and wearing garters, should
be reviewed. Weight control can be encouraged because obesity can
interfere with venous return. Tobacco use should be discouraged because it
may cause arterial spasms. Immobility and hypotension should be
prevented to avoid thrombus formation. Figure 17-1 illustrates exercises
that may benefit patients with peripheral vascular disease. Yoga and tai chi
can also promote circulation. In addition, Buerger-Allen exercises (see Box
17-6) may be prescribed, and the patient and family members or caregivers
will need to learn how they are done correctly and comfortably. Instruction
in the correct use of support hose or special elastic stockings is important.
FIGURE 17-1 Foot and toe exercises. A. Foot flexion. B.

Foot extension. C. Curling toes. D. Moving toes apart.
Providing Foot Care

Persons with peripheral vascular disease must pay special attention to the
care of their feet, which should be bathed and inspected daily. To avoid
injury, patients should not walk in bare feet. Any foot lesion or
discoloration should be promptly brought to the attention of the physician
or nurse. These patients are at high risk for developing fungal infections
from the moisture produced by normal foot perspiration; it is not unusual
for older people to develop fungal infections under their nails, emphasizing
the importance of regular, careful nail inspection. If untreated, a simple
fungal infection can lead to gangrene and other serious complications.
Placing cotton between the toes and removing shoes several times during
the day will help keep the feet dry. Shoes should be large enough to avoid
any pressure and safe enough to prevent any injuries to the feet; they should
be aired after wearing. Laces should not be tied tightly because they can
exert pressure on the feet. Colored socks may contain irritating dyes and
would be best to avoid; socks should be changed regularly. Although the
feet should be kept warm, the direct application of heat to the feet (as with
heating pads, hot water bottles, and soaks) can increase the metabolism and
circulatory demand, thereby compounding the existing problem.
Managing Problems Associated With Peripheral

Vascular Disease
Ischemic foot lesions may be present in patients with peripheral vascular
disease. If eschars are present, they should be loosened to allow drainage.
Careful debridement is necessary to avoid bleeding and trauma; chemical
debriding agents may be useful. Systemic antibiotic agents can be helpful in
controlling cellulitis. Topical antibiotics usually are not used because
epithelialization must occur before bacterial flora can be destroyed.
Analgesics may be administered to relieve associated pain. Good nutrition,
particularly an adequate protein intake, and the maintenance of muscle
strength and joint motion are essential. Various surgical procedures may be
used in treating ischemic foot lesions, including bypass grafts,
sympathectomies, and amputations.
Loss of a limb may represent a significant loss of independence to older
people, regardless of the reality of the situation. With an altered body
image, new roles may be assumed as other roles are forfeited. Patients and
their families need opportunities to discuss their fears and concerns. Making
them aware of the likelihood of a normal life and the availability of
appliances that make ambulation, driving, and other activities possible may
help reduce anxieties and promote a smoother adjustment to the amputation.
The rehabilitation period can be long for older adults and may necessitate
frequent motivation and encouragement by nursing staff.
Promoting Normality
An often unasked question of older patients relates to the impact of their
cardiovascular condition on sexual activity. They may be reluctant to
inquire because they fear being ridiculed or causing shock that “someone
their age would still be interested in sex.” They may resign themselves to
forfeiting sexual activity under the misconception that they will further
harm their hearts; research has demonstrated that patients often place
unnecessary restrictions on sexual activities following heart attacks. Nurses
should encourage discussion of this subject and introduce the topic if
patients seem unable to do so themselves. If there is fear of injuring the
heart by resuming sexual activity, the nurse should provide realistic
explanations, including when sex can be resumed, how medications can
affect sexual function, how to schedule medications for beneficial impact
during sexual activity, and sexual positions that produce the least cardiac
strain.
COMMUNICATION TIP
Nurses should approach questions and discussions of the impact of
cardiovascular conditions on sexual function in a direct, matter-of-fact
manner. Avoid making assumptions that could interfere with open
discussions, such as that sex isn’t an issue due to advanced age, health
status, or widowhood. Offer patients realistic explanations about the
relationship of cardiovascular conditions and sexual function and
invite questions.
Relaxation and rest are both important in the treatment of

cardiovascular disease, and it is wise to remember that a patient who is at
rest is not necessarily relaxed. The stresses from hospitalization, pain,
ignorance, and fear regarding disability, alterations in lifestyle, and potential
death can cause the patient to become anxious, confused, and irrational.
Reassurance and support are needed, including full explanations of
diagnostic tests, hospital or institutional routines, and other activities. The
nurse must provide opportunities for patients and their families to discuss
questions, concerns, and fears. Realistic explanations of any required
restrictions and lifestyle changes should emphasize that patients need not
become “cardiac cripples” just because they have a cardiac disease. Most
patients can live a normal life and need to be reassured of this. (Refer to the
Resources list at the end of the chapter for organizations with resources to
help patients live with cardiovascular disorders.)

The benefits of digitalis (foxglove) in treating heart disease have stimulated
interest in the use of other herbs for preventing and treating cardiovascular
disorders; these include garlic, hawthorn, ginger, and ginkgo biloba. Niacin,
vitamins E and K, and omega-3 fatty acids also have been recommended to
promote cardiovascular health. Although there may be value in their use, at
this time there is insufficient evidence to support their use over
conventional therapies (National Center for Complementary and Integrative
Health, 2020). Patients are wise to discuss the use of medicinal herbs and
nutritional supplements with their health care practitioners and to avoid
exceeding recommended dosages.
Some of the nonconventional measures to facilitate deep relaxation and
reduce stress can be effective in managing heart disease. For example,
meditation has been shown to increase blood flow and oxygen
consumption; biofeedback, guided imagery, tai chi, and yoga have lowered
blood pressure and heart rate; and acupuncture has lowered blood pressure
(National Center for Complementary and Integrative Health, 2020).
Some patients may find yoga beneficial to their circulation because the
various asanas (postures) used in yoga increase circulation because of the
effects on the endocrine glands and nerve plexuses. Acupressure massage
techniques using rubbing, kneading, percussion, and vibration can improve
circulation. The herb ginkgo biloba has shown promise as being effective in
improving cerebral and peripheral circulation. The future may hold
additional noninvasive measures to improve circulation.
Although the full benefits of complementary therapies are in the process
of being discovered, these measures are less intrusive and less expensive
than conventional treatments and, for the most part, carry minimal risk.
Nurses should consider the use of these therapies to prevent heart disease
and complement conventional treatments when pathology exists.
CONSIDER THIS CASE
Although 68 years of age, Ms. U has

continued to carry a full-time teaching load at the university and had no
plans of retirement in the foreseeable future. While hiking last week, Ms.
U developed chest pain and went to the hospital emergency department for
evaluation. She was diagnosed to have a myocardial infarction and, after a
brief hospitalization, was sent home on a thrombolytic agent.
Because she follows a healthy diet and exercises regularly, the
cardiologist recommends no other treatment but does want to see Ms. U at
regular intervals. Ms. U is now afraid to resume her physical activities and
is contemplating retirement because of “her heart condition.”
THINK CRITICALLY
1. What do you assess to be the issues with Ms. U?
2. What could you do to assist her?

Relationship between caregiver burden and

family functioning in family caregivers of older
adults with heart failure
Source: Ghasemi, M., Arab, M., & Shahrbabaki, M. (2020). Journal of
Gerontological Nursing, 46(6):25–33.
To improve outcomes and prevent hospitalization, persons with a
history of heart failure need to adhere to dietary restrictions and medication
schedules, along with other measures to promote their health. Due to
advanced age and/or the limited function of these individuals, they may
need the assistance and support of family caregivers. Having the assistance
and support of family caregivers has been linked to better compliance with
the medical plan of care and lower hospital readmission rates.
This cross-sectional study investigated the relationship between
caregiver burden and family functioning in a group of caregivers of older
persons with heart failure. The Zarit Burden Inventory and the Family
Assessment Device (based on the McMaster Model of Family functioning)
were used to determine the relationship among variables. The results
showed a significant correlation between the burden family caregivers
carried and the level of family functioning in that the greater the caregiving
burden, the poorer the level of family functioning.
Although the support of family caregivers can significantly impact the
well-being of individuals with heart failure, it can have negative effects on
caregivers’ physical, psychological, and social health. In addition to
providing education to caregivers about fulfilling the relative’s care needs
and assuring their competencies to do so, nurses need to assess the ability of
caregivers to fulfill their own self-care needs, balance caregiving with other
responsibilities, set limits, and obtain assistance if needed. Providing
education as to how caregivers can stay healthy themselves while
caregiving can be an important component of the care plan. During each
contact with family caregivers, the nurse should assess the physical,
emotional, and social well-being of the caregivers and discuss the impact
the caregiving is having on the total family unit. In this situation, the nurse
needs to remember that the entire family is the patient.
PRACTICE REALITIES
You are conducting a blood pressure screening and health education
program at a local senior citizen center. One of the participants, a 76-year-
old retired single man, is found to have a slightly elevated blood pressure.
When you bring this to his attention, he acknowledges that he has had a
history of this and that his doctor advised him to reduce his sodium intake.
“That’s fine to say,” says the gentleman, “but I don’t cook and have a
limited income. Most times, I eat cheap carryout or snack foods. Even if I
could afford fresh fruits, vegetables, and fish, they don’t sell them at the
local convenience store and I don’t drive. I just have to make the best of
what I’ve got.”
You learn that this man’s financial, transportation, and food preparation
issues are real as he lives in a basic studio apartment in a poor section of the
city.
How could you assist this man?

1. How does the lifestyle of the average American contribute to the risk
of developing cardiovascular disease with age?
2. List the complications to the general health status of the older adult
that can arise as a result of a cardiovascular disorder.
3. Outline general topics you would address when teaching an older
individual who is recovering from a myocardial infarction.
4. What measures could you advise young adults to incorporate into their
health practices that would promote cardiovascular health in late life?
questions.
The home health nurse is visiting Mr. Hatfield, a 78-year-old who

recently fractured his ankle. Mr. Hatfield is now recuperating in the
apartment he shares with his wife of 52 years.Nurse’s Notes
1100:
The nurse notices that the client’s wife appears pale and weary, and
the apartment appears untidier than it has been during previous visits.
When the nurse asks Mrs. Hatfield if she has any concerns about the
health of either her husband or herself, she simply replies, “Oh, I’m just
really tired. There is a lot to keep up with now that Keith is laid up with
this broken ankle.” Mr. Hatfield adds, “She won’t complain, but I know
she is really, really tired and she been getting dizzy quite a bit lately.” It
is then that Mrs. Hatfield volunteers that she has had a few episodes she
describes as “my heart sort of flutters, but it doesn’t last too long.”
Chapter Summary
A variety of changes gradually occur to the cardiovascular system with age.
Most older adults are able to function adequately despite these changes;
however, when faced with increased demands on the heart, the differences
in the older heart become more apparent.
Practices throughout the lifetime affect cardiovascular health in late
life; these practices include a low-fat diet, maintenance of weight within an
ideal range, regular physical exercise, effective stress management, and the
avoidance of cigarette smoking, excessive alcohol consumption, and use of
illegal drugs.
Although cardiovascular disease kills significantly more women than
does breast cancer, it often does not receive the same attention, so women
might not be aware of the risk. Increased education of women about their
risks and the ways in which symptoms could present themselves are
needed.
The incidence of hypertension increases with age, making it the most
prevalent cardiovascular disease of older adults. Due to the risks associated
with antihypertensive medications, alternatives to these drugs should be
attempted unless contraindicated. Older adults also are at greater risk of
experiencing postural hypotension. Nurses should review factors that
contribute to this risk and reinforce the importance of changing positions
slowly.
CHF is one of the leading causes of hospitalization for older persons.
Although the symptoms can appear similarly to younger adults with this
diagnosis, the risk for skin breakdown from the edema and poor tissue
perfusion associated with this condition is greater in older adults.
The higher occurrence of conditions that cause older adults to be
immobile and malnourished results in pulmonary emboli being of high
incidence in this population. Like many conditions, pulmonary emboli can
present atypically in older adults, which can delay diagnosis.
Most adults over age 70 have some degree of coronary artery disease.
Recognition of anginal syndrome and myocardial infarction can be delayed
due to atypical presentation. Patient education to avoid factors that
aggravate this problem is beneficial.
The risk of coronary artery disease associated with elevated total
cholesterol increases with age, especially in individuals with uncontrolled
diabetes, hypothyroidism, uremia, and nephrotic syndrome or those who are
using corticosteroids or thiazide diuretics.
Atrial fibrillation is the most common sustained arrhythmia and the
major contributing factor to ischemic strokes in older adults. Because the
affected individual may not experience overt symptoms in the early stage,
careful assessment of heart rate and quality during the assessment is
important.
Unlike atherosclerosis, which generally affects the large vessels coming
from the heart, arteriosclerosis most often affects the smaller vessels
farthest from the heart. Persons with diabetes, who have a high risk of
developing peripheral vascular problems and associated complications,
commonly display diabetes-associated neuropathies and infections that
affect vessels throughout the entire body.
Advanced arteriosclerosis is usually responsible for the development of
aneurysms, although they may also result from infection, trauma, syphilis,
and other factors. Aneurysms of the abdominal aorta most frequently occur
in older people. Rapid treatment is necessary to avoid rupture.
Lack of exercise, jobs entailing a great deal of standing, and loss of
vessel elasticity and strength associated with the aging process contribute to
varicosities being a common problem in late life. These individuals are at
risk for falls from dizziness and ulcerative lesions from the skin being more
susceptible to trauma and infection.
Nurses play an important role in the cardiovascular health of older
adults by educating older adults in preventive measures, assisting them with
the prevention of complications when cardiovascular conditions are present,
assuring treatments are administered properly, promoting interventions to
improve circulation, and aiding them to achieve as normal a lifestyle as
possible.
Online Resources
American Heart Association
https://www.heart.org
Heart Disease Patient Education Handouts
https://www.cdc.gov/heartdisease/materials_for_patients.htm
Mended Hearts (for patients with heart disease)
https://www.mendedhearts.org
National Amputation Foundation
www.nationalamputation.org
National Heart, Lung, and Blood Institute
https://www.nhlbi.nih.gov
References
Almed, T. (2020). The role of revascularization in chronic stable angina: Do we have an answer?
Cureus, 12 (5), e8210. doi: 10.7759/cureus.8210.
American heart Association. (2020). Understanding blood pressure readings. Retrieved July 6, 2020
from https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-
readings
Biaggioni, I. (2020). Orthostatic hypotension in the hypertensive patient. American Journal of
Hypertension, 31 (12), 1255–1259.
Fernandez-Jimenez, R., Wang, T. J., Fuster, V., & Blot, W. J. (2020). Low-dose aspirin for primary
prevention of cardiovascular disease: Use patterns and impact across race and ethnicity in the
Southern Community Cohort Study. Journal of the American Heart Association, 8 (24),
e013404. doi: 10.1161/JAHA.119.013404.
Ferri, N., & Corsini, A. (2020). Clinical pharmacology of statins: An update. Current Atherosclerosis
Reports, 7 (26). doi: 10.1007/s11883-020-00844-w.
Kashino, I., Eguchi, M., Miki, T., Kochi, T., Nanri, A., Kabe, I., & Mizoue, T. (2020). Prospective
association between whole grain consumption and hypertension: The Furukawa Nutrition and
Health Study. Nutrients, 12 (4), 902. doi: 10.3390/nu12040902.
Lee, M. P., Glynn, R. J., Schneeweiss, S., Lin, K. J., Patorno, E., et al. (2020). Risk factors for heart
failure with preserved or reduced ejection fraction among Medicare beneficiaries: Application
of competing risks analysis and gradient boosted model. Clinical Epidemiology, 12 , 607–616.
doi: 10.2147/CLEP.S253612.
Matsutomo, T. (2020). Potential benefits of garlic and other dietary supplements for the management
of hypertension. Experimental and Therapeutic Medicine, 19 (2), 1479–1484.
National Center for Complementary and Integrative Health. (2018). Hypertension. Retrieved July 5,
2020 from https://www.nccih.nih.gov/health/hypertension-high-blood-pressure
National Center for Complementary and Integrative Health. (2020). Cardiovascular disease.
Retrieved July 6, 2020 from https://www.nccih.nih.gov/health/cardiovascular-disease
National Heart, Lung, and Blood Institute. (2019). Description of the DASH eating plan. Retrieved
July 7, 2020 from http://www.nhlbi.nih.gov/health/health-topics/topics/dash/
Ness, W. (2019). Step by step guide to the Ornish Diet: A beginners guide and 78-day meal plan for
the Ornish Diet. New Orleans, LA: Tiny Shoe Media.
Ornish, D. (2008). Dr, Dean Ornish’s program for reversing heart disease. New York, NY: Ivy
Books.
Ouyang, P. (2020). Assessing cardiovascular risk with C-reactive protein. Heart and Vascular
Institute, Johns Hopkins Medicine Site. Retrieved July 5, 2020 from
https://www.hopkinsmedicine.org/heart_vascular_institute/centers_excellence/women_cardiova
scular_health_center/patient_information/health_topics/c_reactive_protein.html
Shufelt, C. L., & Manson, J. E. (2020). Aspirin for primary prevention of cardiovascular disease in
women. Menopause, 27 (5), 605–606.
CHAPTER 18
Digestion and Bowel Elimination
Chapter Outline
Effects of Aging on Gastrointestinal Health
Gastrointestinal Health Promotion
Selected Gastrointestinal Conditions and Related Nursing
Considerations
Dental Problems
Dysphagia
Hiatal Hernia
Esophageal Cancer
Peptic Ulcer
Colorectal Cancer
Flatulence
Fecal Impaction
Fecal Incontinence
Acute Appendicitis
LEARNING OBJECTIVES
1. Describe how aging affects gastrointestinal health.

2. Discuss measures to promote gastrointestinal health in older adults.
3. List symptoms and management of selected gastrointestinal conditions
in older adults.
TERMS TO KNOW
Anorexialack of appetite
Cholelithiasisthe formation or presence of gallstones in the gallbladder
Diverticulitisinflammation or infection of the pouches of intestinal
mucosa
Dysphagiadifficulty swallowing
Esophageal dysphagiadifficulty with the transfer of food down the
esophagus
Fecal incontinenceinvoluntary passage of stool
Flatusgas in intestinal tract
Gingivitisinflammation of the gums surrounding the teeth
Hiatal herniaportion of the stomach protrudes through an opening in the
diaphragm
Oropharyngeal dysphagiadifficulty transferring food bolus or liquid
from the mouth into the pharynx and esophagus
Periodontal diseaseinflammation of the gums extending to the
underlying tissues, roots of teeth, and bone
Presbyesophagusage-related changes to the esophagus causing reduced
strength of esophageal contractions and slower transport of food down
the esophagus
Digestion and bowel elimination are important functions of the

gastrointestinal tract. Significantly fewer older people die from
gastrointestinal problems than from diseases of other major body systems;
however, these problems often are the source of many complaints and
discomforts in this age group. Indigestion, belching, diarrhea, constipation,
nausea, vomiting, anorexia, weight gain or loss, and flatus are among the
bothersome problems that increasingly occur, even in the absence of
organic cause. Gallbladder disease and various cancers of the
gastrointestinal tract increase in incidence in later life. In addition, poor
nutrition, medications, emotions, inactivity, and a variety of other factors
influence the status of gastrointestinal health.
Usually, older adults are aware of their gastrointestinal discomforts and
use various measures to manage symptoms of these problems. In some
situations, misinformation can interfere with good gastrointestinal health
(e.g., assuming that tooth loss is normal or believing a daily laxative is
essential); in other circumstances, self-treatment can delay the diagnosis of
pathologies (e.g., using antacids to mask symptoms of stomach cancer).
Gerontological nurses play an important role in promoting gastrointestinal
health in older adults and intervening when problems are identified.
EFFECTS OF AGING ON
GASTROINTESTINAL HEALTH
The gastrointestinal system and accessory structures experience significant
changes with age (see Chapter 5). The tongue atrophies, affecting the taste
buds and decreasing taste sensations. Changes in taste sensations can also
be related to xerostomia (dry mouth), the effects of some medications,
diseases, and smoking. Saliva production decreases and swallowing may be
more difficult. There is thinning of the oral mucosa and a weakening of the
muscles involved in mastication, leading to a reduction in chewing
efficiency. Gingival recession of the buccal surfaces of the teeth loosens
tooth support. Presbyesophagus , the degenerative changes in the smooth
muscle lining of the lower esophagus, results in weaker esophageal
contractions and weakness of the sphincter. As esophageal and stomach
motility decrease, food can remain in the upper gastrointestinal system for a
longer period of time; as a result, there is a risk of indigestion and
aspiration. Decreased elasticity of the stomach reduces the amount of food
that the stomach can accommodate at one time. The stomach has a higher
pH as a result of the declines in hydrochloric acid and pepsin; this
contributes to an increased incidence of gastric irritation in late life. The
reduced presence of pepsin can interfere with the absorption of protein,
whereas the decrease in hydrochloric acid can interfere with the absorption
of calcium, iron, folic acid, and vitamin B12. There are fewer cells on the
absorbing surface of the intestinal walls affecting the absorption of
dextrose, xylose, calcium, iron, and vitamins B, B12, and D.
Slower peristalsis, inactivity, reduced food and fluid intake, drugs, and a
diet low in fiber are responsible for the high incidence of constipation in
older individuals. Decreased sensory perception may cause the signal for
bowel elimination to go unnoticed, which can promote constipation. There
is also a tendency toward incomplete emptying of the bowel with one bowel
movement; 30 to 45 minutes after the initial movement, the remainder of
the bowel movement may need to occur, and if not heeded, problems may
develop.
The structure of the gallbladder and bile ducts is unchanged with age;
bile salt synthesis decreases, however, contributing to the risk of gallstone
development. The pancreas experiences fibrosis, atrophy, and fatty acid
deposits, along with a reduction in pancreatic secretions; this can affect the
digestion of fats and contribute to an intolerance for fatty foods. Although
liver size decreases with age, liver function remains within normal limits.
Hepatic blood flow can be reduced as a result of decreased cardiac output.
GASTROINTESTINAL HEALTH
PROMOTION
A variety of gastrointestinal conditions can be avoided by good health
practices. Good dental hygiene (Box 18-1) and regular visits to the dentist
can prevent disorders that can threaten nutritional intake, general health,
comfort, and self-image.
BOX 18-1 Oral Health Practices for Older

Adults
Brush all tooth surfaces and the tongue at least twice daily with a
soft-bristled toothbrush and fluoridated toothpaste. Use an up-and-
down brushing motion. If arthritis, weakness, or other problems
interfere with the ability to adequately brush teeth, obtain a large-
handled, battery-powered, or electric-powered toothbrush.
Floss between teeth daily. Floss aids are available to compensate for
arthritic fingers or other problems that can interfere with flossing.
If mouthwash is used, avoid those that contain alcohol. (Mouthwash
is not a substitute for brushing.)
Swab sticks (e.g., lemon–glycerin) should be avoided as they dry
the oral mucosa and erode tooth enamel.
Brush the teeth or rinse the mouth after consuming candy or other
sweets.
If dentures are worn, remove them at night and soak them in water.
Clean the dentures and the gums of the mouth before replacing the
dentures in the mouth.
If hard candy and gum are desired, use the sugar-free varieties.
Visit a dentist every 6 months. Less frequent visits are acceptable if
a complete set of dentures is worn, but to detect oral diseases,
dental evaluation remains important; consult with a dentist as to
suggested frequency of visit.

The use of alcohol or citrus-based swab sticks (e.g., lemon–glycerin) for
oral hygiene is not recommended because they can dry the mucosa and
erode tooth enamel. Brushing, flossing, and rinsing the oral cavity with
mouthwash will promote oral health.
The proper quantity and quality of foods can enhance general health
and minimize the risk of indigestion and constipation. (See Chapter 11 for
more specific information on ways to promote nutritional health.)
Knowledge of the relationship of medications to gastrointestinal health is
also important.
Natural means to promote bowel elimination is important for older
adults to incorporate into their daily routines, including good fluid intake, a
diet rich in fruits and vegetables, activity, and the establishment of a regular
time for bowel elimination (Fig. 18-1). Dietary fiber intake of 20 to 35 g/d
is advisable; however, if fiber intake has been low, the amount should be
gradually increased to prevent gas, bloating, diarrhea, and other symptoms.
If a person dislikes eating high-fiber foods, these foods can be added to
other foods (e.g., adding wheat bran to ground beef or muffins) to mask the
taste. Plenty of fluids should accompany increased fiber intake. Because of
the tendency for incomplete emptying of the bowel at one time, opportunity
should be provided for full emptying and for repeated attempts at
subsequent elimination. Sometimes, an older person’s request to be taken to
the bathroom or to have a bedpan for bowel elimination shortly before a
movement occurs is viewed as an unnecessary demand and ignored; it is
then wondered why bowel incontinence results. It is useful for older adults
to attempt a bowel movement following breakfast, because the morning
activity and ingestion of food and fluid following a period of rest stimulate
peristalsis.
FIGURE 18-1 A diet rich in fruits and vegetables is one
natural means to promote bowel elimination.
Astute assessment can reveal problems that patients may have omitted
sharing with their health care providers and can identify practices that
interfere with good health (Assessment Guide 18-1). Table 18-1 lists
possible nursing problems related to gastrointestinal conditions.
TABLE 18-1 Nursing Problems Related to Gastrointestinal

Problems

GASTROINTESTINAL FUNCTION
General appearance. Pallor can be associated with blood loss from
gastrointestinal bleeding. Weakness and fatigue can be due to
malnutrition, fluid and electrolyte imbalances, or bleeding. Note
obesity or unusual thinness.
Odors. Unusual breath odors can be associated with disorders.
Halitosis can indicate poor oral hygiene practices, disease of the oral
cavity or esophagus, lung abscess or infection, liver disease, or
uremia.
Skin. Dry skin and skin with poor turgor can indicate dehydration;
scaling, itching, discolored skin, or skin eruptions can result from a
variety of nutritional deficiencies.
INTERVIEW
Carefully structured questions can reveal hidden problems, particularly in
older adults who accept some gastrointestinal symptoms as normal or who
have lived with these symptoms for so long that they no longer consider
them abnormalities. Questions should review topics such as the following:
Status of teeth or dentures. “When was your last dental exam? How
do you care for your teeth or dentures? When did you get your
dentures; how do they fit? Do you have any pain, bleeding, or other
symptoms?”
Taste, appetite. “Does food taste differently to you than it did in the
past? What do you do to make food taste better? How is your
appetite; how does it compare to earlier years?”
Symptoms. “Do you ever have a sore mouth, difficulty swallowing,
choking, a sense that something has ‘gone down the wrong hole,’
nausea, vomiting, bleeding from your mouth, blood in your vomitus
or stool, pain or burning in your stomach or intestines, diarrhea,
constipation, gas, bleeding from your rectum?” Specific questions
should be asked to explore each positive response.
Weight. “Have you noticed any recent changes in your weight? Have
you been trying to gain or lose weight?”
Digestion. “How often do you have indigestion? What seems to cause
it and how is it managed? Is there a sense of fullness or discomfort in
the chest after meals? Does regurgitation or belching ever occur?”
Elimination. “How often do you have a bowel movement? Do you
have to take special measures to move your bowels? If so, what are
they? Do you strain to have a bowel movement? Is there ever blood
in your stools or on the toilet tissue? What are the color and
consistency of your bowel movements?”
Diet. “Describe what and when you eat in a typical day. Do foods
have a different taste to you? Can you shop for and cook meals on
your own? Has your eating pattern changed?”
Colorectal screening. Ask if colorectal screening (e.g., fecal occult
blood testing, sigmoidoscopy, and colonoscopy) has been done.
Further questions may be necessary in response to certain problems

that emerge through the interview.
Inspection, auscultation, percussion, and palpation aid in validating
problems identified through the interview and in detecting undisclosed
disorders. A systematic examination of the gastrointestinal system would
review the following:
Lips. Note symmetry, color, moisture, and general condition. Because

capillaries are abundant in the lips, a bluish discoloration could
reflect poor oxygenation. Cracks and fissures can be associated with
riboflavin deficiencies, jagged teeth, or poorly fitting dentures.
Oral cavity. With a tongue depressor and flashlight, inspect the
mouth. The mucous membrane should be moist and pink. Black
persons may have a pigmented mucosa. Excessive dryness of the
mucosa or tongue can indicate dehydration. Note lesions or areas of
irritation, which could be caused by teeth, dentures, or pathologic
conditions. White beads in the oral cavity can be a sign of moniliasis
infections and should be cultured. Bleeding and swollen gums are
most commonly associated with periodontal disease. Swollen gums
also can result from phenytoin therapy or leukemia. Lead poisoning
causes a bluish black line along the edge of the gums, but only if
teeth are present. Older persons can develop lead poisoning due to
occupational exposure or contact within their home environment.
Tongue. Examine the top and bottom surface of the tongue. A coating
on the tongue can be associated with poor hygiene or dehydration. A
smooth, red tongue occurs with iron, vitamin B12, or niacin
deficiencies. Thick, white patches can indicate leukoplakia, which
could be precancerous. Give attention to lesions on the tongue that
have been present for several weeks because they can be cancerous;
they more frequently occur on the bottom surface than on the top of
the tongue. Varicosities on the undersurface of the tongue are not
unusual findings. Determine if the individual can move the tongue
side to side and up and down.
Pharynx. During normal swallowing, the vagus nerve causes the soft
palate to rise and block the nasopharynx so that aspiration is
prevented. To test this function, press a tongue depressor on the
middle of the tongue, but not so far back that gagging results, and ask
the patient to say “ah.” The soft palate should rise when “ah” is said.
If soreness, redness, or white patches are present in the throat, a
culture is warranted.
Abdomen. Have the patient void and then lie supine on a firm surface;
inspect the abdomen. Ask about any scars that are present; the patient
may have forgotten to mention an appendectomy that occurred 50
years ago. Striae, or stretch marks, are pink or blue if newly
developed and silvery white if old; they can result from obesity,
ascites, pregnancy, or tumors. Note rashes, indentations, and other
findings. Both sides of the abdomen should be symmetrical with no
bulging areas. A symmetrical distension most commonly is due to
obesity but can also be associated with ascites or tumors. Central,
lower abdominal (i.e., below the umbilicus) distension occurs with
bladder distension or tumors of the uterus or ovaries. Central, upper
abdominal distension may result from gastric dilation or pancreatic
tumors. The abdomen should rise and fall in conjunction with
respirations. Peristaltic activity may be observed; sometimes, gently
flicking a finger on the abdomen will stimulate peristalsis. With the
diaphragm of the stethoscope, bowel sounds can be heard about once
every 5 to 15 seconds; they usually are irregular. If no bowel sounds
are heard, try stimulating them by flicking a finger on the abdomen.
No sounds for at least 5 minutes can indicate the absence of bowel
sounds, and medical evaluation would be warranted. Loud, gurgling
sounds indicate increased peristaltic activity. Palpation of the
abdomen should normally reveal no masses.
Rectum. Perform a rectal examination with the patient in a standing
position, bent over the examination table, or in a left lateral position
with the right hip and knee flexed. Inspect the perianal area first.
Flaccid skin sacs around the anus are hemorrhoids. Fissures, tumors,
inflammation, and poor hygienic practices may be noted. Ask the
patient to bear down, which could make additional hemorrhoids or
rectal prolapse visible. Ask the patient to bear down again and insert
a lubricated gloved finger into the anal canal. Assure the patient that
it is normal to feel as if a bowel movement is imminent. The
sphincter should tighten around the finger. Masses or other
abnormalities along the rectal wall should be noted. A hard mass that
prevents full palpation of the rectum may be a fecal impaction.
Impactions may or may not be movable. If it is a fecal impaction,
fecal material will be found on the glove or a discharge will occur
when the examining finger is withdrawn.
Stool. Obtain a stool specimen; fecal material withdrawn during the
rectal examination can give clues to problems. Black, tarry stools can
be associated with the ingestion of iron preparations or iron-rich
foods or can indicate upper gastrointestinal bleeding; bright-red blood
accompanies bleeding from the lower bowel or hemorrhoids; pale,
fatty stool can occur with absorption problems; gray or tan stool is
caused by obstructive jaundice; and mucus in the stool may result
from inflammation.
COMMUNICATION TIP
If during the interview patients deny any problems with constipation
when asked about their bowel elimination, it could be beneficial to ask
them what measures they take to maintain bowel regularity. By
probing, it may be discovered that patients are routinely using
laxatives, giving themselves enemas, or experiencing regular bouts of
diarrhea. Asking specific questions about these issues can aid in
revealing problems that otherwise could be missed.
SELECTED GASTROINTESTINAL
CONDITIONS AND RELATED
NURSING CONSIDERATIONS

Saliva serves several important functions, such as lubricating soft tissues,
assisting in remineralizing teeth, promoting taste sensations, and helping to
control bacteria and fungus in the oral cavity. Reduced saliva, therefore, can
have significant consequences.
Dry mouth can result from a variety of factors in addition to age-related
slight declines in saliva secretion. Many of the medications used by older
persons (e.g., diuretics, antihypertensives, anti-inflammatories, and
antidepressants) can affect salivation. Sjögren’s syndrome, a disease of the
immune system, can reduce salivary gland function and cause severe
dryness of the mucous membrane. Mouth breathing and altered cognition
also contribute to this problem.
Persons with dry mouth benefit from frequent oral hygiene, not only
because of the comfort obtained but also to reduce the higher risk of dental
disease related to dry mouth. Saliva substitutes (e.g., Biotene, Salivart
Synthetic Saliva) are available as gels and rinses; however, sipping water to
relieve dryness and stimulating saliva production with hard sugarless candy
and gum are effective for many individuals.
Dental Problems
Dental care is important throughout an individual’s life. Dental examination
can be instrumental in the early detection and prevention of many problems
that affect other body systems. Poor condition of teeth can restrict food
intake, which can cause constipation and malnourishment (see Chapter 11);
it can also detract from appearance, which can affect socialization, and this
can result in a poor appetite, which also can lead to malnourishment.
Periodontal disease can predispose older adults to systemic infection.
Although dental care is important in preventing these problems, financial
limitations prevent many older persons from seeking dental attention. Some
have the misconception that dentures eliminate the need for regular visits to
the dentist; others, like many younger persons, fear the dentist. The nurse
should encourage regular dental examination and promote dental care,
explaining that serious diseases can be detected by the dentist and helping
patients find free or inexpensive dental clinics. Understanding how modern
dental techniques minimize pain can alleviate fears. Although older persons
may not have had the benefit of fluoridated water or fluoride treatments
when younger, topical fluoride treatments are as beneficial to the teeth of
older persons as they are to younger teeth. The nurse should instruct
patients to inform their dentists about health problems and medications they
take to help them determine how procedures need to be modified, what
healing rate to expect, and which medications should not be administered.
Dental problems can be caused by altered taste sensation, a poor diet, or
a low-budget carbohydrate diet with excessive intake of sweets, which can
cause tooth decay. Deficiencies of vitamin B complex and calcium,
hormonal imbalances, hyperparathyroidism, diabetes, osteomalacia,
Cushing’s disease, and syphilis can be underlying causes of dental
problems, and certain drugs, such as phenytoin, which can cause gingivitis ,
or antihistamines and antipsychotics, which cause severe dry mouth, can
play a part. The aging process itself takes its toll on teeth. Surfaces are
commonly worn down from many years of use, varying degrees of root
absorption occur, and loss of tooth enamel can increase the risk of irritation
to deeper dental tissue. Although benign neoplastic lesions develop more
frequently than malignant ones, cancer of the oral cavity, especially in men,
increases in incidence with age, as does moniliasis, which is often
associated with more serious problems, such as diabetes or leukemia. It
should not be assumed that all white lesions found in the mouth are
moniliasis; biopsy is important to make sure they are not cancerous.
Periodontal disease, which damages the soft tissue surrounding the teeth
and supporting bones, has a high incidence among older adults and is a
major cause of tooth loss. Dental caries occur less frequently in older
people, but they remain a problem.
KEY CONCEPT
With age, the teeth experience a wearing down on the surfaces, decrease
in the size and volume of pulp, increased brittleness, varying degrees of
root absorption, and a loss of enamel.
Good oral hygiene is especially important to older persons, who already

may be having problems with anorexia or food distaste. Teeth, gums, and
tongue should be brushed regularly using a soft toothbrush, which also can
be used in gentle gum massage for people with dentures. Brushing is
superior to using swabs, even for the teeth of unconscious patients. Daily
flossing of natural teeth should also be performed. Because the buccal
mucosa is thinner and less vascular with age, trauma to the oral cavity
needs to be avoided. The nurse should notify the dentist and physician of an
atonic or atrophic tongue, lesions, mucosa discoloration, loose teeth,
soreness, bleeding, or any other problem identified during inspection and
care of the oral cavity.
Dysphagia
The incidence of swallowing difficulties increases with age. As swallowing
depends on complex mechanisms involving several cranial nerves and the
muscles of the mouth, face, pharynx, and esophagus, anything that impacts
those structures can cause dysphagia . Gastroesophageal reflux disease
(GERD) is a common cause, as are stroke and structural disorders.
Dysphagia can be oropharyngeal, characterized by difficulty transferring
food bolus or liquid from the mouth into the pharynx and esophagus and
more common in persons with neurologic damage, or esophageal,
involving difficulty with the transfer of food down the esophagus and more
common in persons with motility disorders, sphincter abnormalities, or
mechanical obstructions caused by strictures. Symptoms can be mild, such
as occasional difficulties swallowing certain types of food, to a complete
inability to swallow.
Careful assessment and observation assist in diagnosing the cause of the
problem. The nurse should ask patients with dysphagia:
When the problem began

What other symptoms accompany the dysphagia (chest pain, nausea,
or coughing)
What types of foods trigger symptoms (e.g., solids or liquids)
If the problem is intermittent or present with every meal
Observing food intake can offer insights into the nature of the problem.
Referral to a speech–language pathologist is essential to developing an
effective plan of care.
Prevention of aspiration and promotion of adequate nutritional status
are major goals in the care of patients with dysphagia. The nurse should
follow the recommendations of the speech–language therapist closely.
Often, a soft diet and thickening of liquids are recommended to promote
ease of swallowing; however, there are various levels of dietary
modification that can be prescribed ranging from pureed to mechanically
altered to regular. Patients with dysphagia should eat in an upright position,
ingesting small bites in an unhurried manner. Verbal cues may be needed.
An easily accessible suction machine is beneficial in the event of choking.
It is important to monitor food intake and weight.
Hiatal Hernia
The incidence of hiatal hernia increases with age, affecting about half of
people in the United States over age 50 years, and is of greater incidence in
older women. There is some thought that the low-fiber diet of Americans
contributes to the high prevalence of this condition. The two types of hiatal
hernia are sliding (axial) and rolling (paraesophageal). The sliding type is
the most common and occurs when a part of the stomach and the junction
of the stomach and esophagus slide through the diaphragm. Most patients
with GERD have this type of hiatal hernia. In the rolling or paraesophageal
type, the fundus and greater curvatures of the stomach roll up through the
diaphragm. Heartburn, dysphagia, belching, vomiting, and regurgitation are
common symptoms associated with hiatal hernia. These symptoms are
especially problematic when the patient is recumbent. Pain (sometimes
mistaken for a heart attack) and bleeding also may occur. Diagnosis is
confirmed by a barium swallow and esophagoscopy.
Most patients are managed medically. If the patient is obese, weight
reduction can minimize the problem. A bland diet may be recommended, as
may the use of milk and antacids for symptomatic relief. Several small
meals each day rather than three large ones help improve hiatal hernias and
may be advantageous to the aged in coping with other age-related
gastrointestinal problems. Eating before bedtime should be discouraged.
Some patients may find it helpful to sleep in a partly recumbent position.
H2 blockers, such as ranitidine, cimetidine, or nizatidine, and proton pump
inhibitors like lansoprazole and omeprazole often are prescribed.
NURSING CARE PLAN 18-1 offers a sample care plan for the patient with
hiatal hernia.

THE OLDER ADULT WITH HIATAL HERNIA
Problem: Acute pain
Nursing Problem: Insufficient nutritional intake
KEY CONCEPT
Several small meals throughout the day, rather than three large ones, not
only are beneficial in the management of hiatal hernia but also have
advantages for the gastrointestinal health of all older adults.
Esophageal Cancer
Although the incidence has been decreasing, most persons affected by
cancer of the esophagus are of advanced age. The most common types are
squamous cell carcinoma and adenocarcinoma. This disease commonly
strikes between the ages of 45 and 70 years and is of higher incidence in
men. African American men with a history of alcoholism and heavy
smoking have a higher incidence of squamous cell esophageal carcinoma.
Poor oral hygiene and chronic irritation from tobacco, alcohol, and other
agents contribute to the development of this problem. Barrett’s esophagus, a
condition in which the normal lining of the esophagus is replaced by a type
of lining usually found in the intestines (intestinal metaplasia), is associated
with an increased risk of developing this cancer (Graham & Tan, 2020).
Dysphagia, weight loss, excessive salivation, thirst, hiccups, anemia,
and chronic bleeding are symptoms of the disease. Unfortunately,
symptoms often are not recognized until the disease is advanced,
contributing to a poor prognosis. Barium swallow, esophagoscopy, and
biopsy are performed as diagnostic measures. Treatment options include
surgical resection, radiation, chemotherapy, laser therapy, and
photodynamic therapy. Benign tumors of the esophagus are rare in older
people.
Peptic Ulcer
In addition to stress, diet, and genetic predisposition as causes, particular
factors are believed to account for the increased incidence of ulcers in older
persons, including longevity; more precise diagnostic evaluation; and the
fact that ulcers can be a complication of chronic obstructive pulmonary
disease, which is increasingly prevalent. Drugs commonly prescribed for
older adults that can increase gastric secretions and reduce the resistance of
the mucosa include aspirin, reserpine, tolbutamide, phenylbutazone,
colchicine, and adrenal corticosteroids. Other risk factors include smoking,
heavy alcoholic beverage consumption, caffeine, stress, and Helicobacter
pylori infection.
Peptic ulcers tend to present with more acute symptoms in older adults,
such as pain, bleeding, obstruction, and perforation. Diagnostic and
therapeutic measures resemble those used for younger adults. Addressing
risk factors is important. The nurse should be alert to complications
associated with peptic ulcer, which are more likely to occur with older
adults, such as constipation or diarrhea caused by antacid therapy and
pyloric obstruction resulting in dehydration, peritonitis, hemorrhage, and
shock.
POINT TO PONDER
In what ways do diet, activity, emotions, and other factors affect your
appetite, diet, digestion, and bowel elimination? Do you notice any
patterns that you could correct, and if so, how?

The incidence of gastric cancer increases with age, occurring most
frequently in people between 50 and 70 years of age, with an average age of
diagnosis of 68 years. It is more prevalent among men, cigarette smokers,
poor socioeconomic groups, and African American, Hispanic, and
Asian/Pacific Islander individuals. Adenocarcinomas account for most
gastric malignancies. Fortunately, the number of new cases in the United
States has been decreasing by 1.5% over the past decade (American Cancer
Society, 2020).
Anorexia, epigastric pain, weight loss, and anemia are symptoms of
gastric cancer; these symptoms may be insidious and easily mistaken for
indigestion problems. Bleeding and enlargement of the liver may occur.
Symptoms related to pelvic metastasis may also develop. Diagnosis is
confirmed by barium swallow and gastroscopy with biopsy. Surgical
treatment consisting of a partial or total gastrectomy is preferred. If detected
early, the prognosis is good, but when advanced, there is a poor prognosis.
A diet low in red meats and high in antioxidants is believed to be helpful in
preventing stomach cancer.
KEY CONCEPT
Symptoms of gastric cancer can be insidious and easily mistaken for
indigestion.
Multiple pouches of intestinal mucosa in the weakened muscular wall of the
large bowel, known as diverticulosis, are common among older persons.
Chronic constipation, obesity, hiatal hernia, and atrophy of the intestinal
wall muscles with aging contribute to this problem. The low-fiber, low-
residue diets that are common in Western societies are a major reason that
diverticulosis is common in this country but rare in many third world
countries. Most cases involve the sigmoid colon; many cases are
asymptomatic. If symptoms are present, they can include slight bleeding, as
well as a change in bowel habits (constipation, diarrhea, or both) and
tenderness on palpation of the left lower quadrant. Usually, a barium enema
identifies the problem. Surgery is not performed unless severe bleeding
develops. Medical management is most common and includes an increase
in dietary fiber intake, weight reduction, and avoidance of constipation.
Bowel contents can accumulate in the diverticula and decompose,
causing inflammation and infection; this is known as diverticulitis .
Although fewer than half the patients with diverticulosis develop
diverticulitis, most patients who do are old. Older men tend to experience
this problem more than any other group.
Overeating, straining during a bowel movement, alcohol, and irritating
foods may contribute to diverticulitis in the patient with diverticulosis.
Abrupt onset of pain in the left lower quadrant, similar to that of
appendicitis but over the sigmoid area, is a symptom of this problem.
Nausea, vomiting, constipation, diarrhea, low-grade fever, and blood or
mucus in the stool may also occur. These attacks can be severely acute or
slowly progressing; although the acute attacks can cause peritonitis, the
slower forms can also be serious because of the possibility of lower bowel
obstruction resulting from scarring and abscess formation. In addition to the
mentioned complications, fistulas to the bladder, vagina, colon, and
intestines can develop. During the acute phase, efforts focus on reducing
infection, providing nutrition, relieving discomfort, and promoting rest.
Usually nothing is ingested by mouth, and intravenous therapy is used.
When the acute episode subsides, the patient is taught to consume a low-
residue diet. Surgery, performed if medical management is unsuccessful or
if serious complications occur, may consist of a resection or temporary
colostomy. Continued follow-up should be encouraged.
Colorectal Cancer
Cancer at any site along the large intestine is common with advancing age.
The sigmoid colon and rectum tend to be frequent sites for carcinoma; in
fact, colorectal cancer is the third most common malignancy in the United
States. Although the pattern of symptoms frequently varies for each person,
some common symptoms include the following:
Rectal bleeding, bloody stools

Change in bowel pattern
Feeling of incomplete emptying of bowel
Anorexia
Nausea
Abdominal discomfort, pain over affected region
Weakness, fatigue
Unexplained weight loss
Anemia
Some older patients ignore bowel symptoms, believing them to be from

constipation, poor diet, or hemorrhoids. The patient’s description of bowel
problems is less reliable than a digital rectal examination, which detects
half of all carcinomas of the large bowel and rectum. Fecal occult blood
testing is effective for early detection of colonic tumors. Diagnostic tests
include colonoscopy with biopsy and CT colonography (virtual
colonoscopy). Surgical resection with anastomosis or the formation of a
colostomy is usually performed. Medical–surgical nursing textbooks can
provide information on this surgery, and nurses should consult them for
specific guidance on caring for patients with this condition.
KEY CONCEPT
The American Cancer Society recommends an annual stool occult blood,
fecal immunochemical test, and digital rectal examination because they
can detect many cancers of the large bowel and rectum. In addition, a
flexible sigmoidoscopy or CT colonography every 5 years or a
colonoscopy every 10 years is advised as an important means to detect
colorectal cancer. Risk factors may warrant more frequent screening.
Colorectal cancer screening is not recommended for persons over age
85.
It is important to realize that a colostomy can present many problems

for older adults. In addition to having to adjust to many bodily changes with
age, a colostomy presents a major adjustment and a threat to a good self-
concept. Older adults may feel that a colostomy further separates them from
society’s view of normal. Socialization may be impaired by the patient’s
concern over the reactions of others or by fear of embarrassing episodes.
Reduced energy reserves, arthritic fingers, slower movement, and poorer
eyesight are among the problems that may hamper the ability to care for a
colostomy, thus causing dependency on others to assist with this procedure.
This need for assistance may be perceived as a significant loss of
independence for older persons. Tactful, skilled nursing intervention can
promote psychological as well as physical adjustment to a colostomy.
Continued follow-up is beneficial to assess the patient’s changing ability to
engage in this self-care activity, identify problems, and provide ongoing
support and reassurance.
Constipation is a common concern for older adults (see Nursing Problem
Highlight 18-1). Many factors can contribute to this problem, including:

CONSTIPATION
Overview
Constipation is a condition in which there is an infrequent passage of dry,
hard stools. Some of the findings consistent with constipation include
decreased frequency of bowel movements (as compared with the patient’s
normal pattern); straining to have bowel movement; hard, dry stools;
abdominal distension and discomfort; palpable mass and sense of pressure
or fullness in the rectum; poor appetite; backache and headache; reduced
activity level; and request for or use of laxatives or enemas.
Age-related decrease in peristalsis, inactivity, immobility, hemorrhoidal
pain, poor dietary intake of fiber and fluids, dehydration, certain diseases
(e.g., hypothyroidism), surgery, dependency on laxatives or enemas, and
side effects of medications (e.g., antacids, calcium, anticholinergics,
barium, iron, and narcotics).
Goal
The patient establishes a regular pattern of bowel elimination and passes a
stool of normal consistency without straining or experiencing discomfort.
Interventions
Establish and maintain record of frequency and characteristics of
bowel movements.
Ensure patient consumes at least 1,300 mL fluids daily (unless
contraindicated).
Review dietary pattern with patient and educate as needed regarding
the inclusion of high-fiber foods in diet; monitor dietary intake.
Assist patient in developing a program to increase activity level as
appropriate.
Assist patient in developing a regular schedule for toileting; provide
toileting assistance as needed; ensure privacy is provided during
toileting; if bedpan must be used, be sure patient is in upright
position, unless contraindicated, and made comfortable.
Consider use of herbs with laxative effects, such as aloe, dandelion
root, cascara sagrada, senna, and rhubarb.
Consult with physician regarding use of vitamin C supplements
several times daily until stool is soft (not to exceed 5,000 mg/d).
Administer laxatives, as prescribed; avoid long-term use of laxatives
unless patient’s condition warrants otherwise.
Monitor for fecal impaction.
Assess patient’s use of laxatives and enemas; if dependency on
laxatives or enemas for bowel elimination exists, educate patient
about hazards associated with this dependency and develop a plan to
gradually taper usage of laxative or enema (abrupt discontinuation is
contraindicated).
Educate patient as to nonpharmacologic means to stimulate bowel
movement.
Inactive lifestyle
Low fiber and low fluid intake
Depression
Laxative abuse
Certain medications, such as opiates, sedatives, and aluminum
hydroxide gels
Dulled sensations that cause the signal for bowel elimination to be
missed
Failure to allow sufficient time for complete emptying of the bowel
A diet high in fiber and fluid and regular activity can promote bowel
elimination, and particular foods that patients find effective (e.g., prunes or
chocolate pudding) can be incorporated into the regular diet. A mixture of
raisins, prunes, dates, and currants can be a nourishing, tasty snack that
promotes bowel elimination. (For individuals with chewing impairments,
this can be blended with yogurt or applesauce.) Providing a regular time for
bowel elimination is often helpful; mornings tend to be the best time for
older adults to empty their bowels. Sometimes rocking the trunk from side
to side and back and forth while sitting on the toilet will stimulate a bowel
movement. Only after these measures have failed should medications be
considered.
KEY CONCEPT
Measures to promote bowel elimination include scheduling a regular
time for this function, incorporating high-fiber foods into the diet, and
rocking the trunk from side to side and back and forth while sitting on
the toilet.
Older persons may need education concerning bowel elimination. The

safe use of laxatives should be emphasized to prevent laxative abuse. The
patient should be aware that diarrhea resulting from laxative abuse may
cause dehydration, a serious threat to life. Dandelion root, cascara sagrada,
senna, and rhubarb are herbs that stimulate bowel movement and can be
taken to prevent constipation.
Older adults in a hospital or nursing home may benefit from an
elimination chart that reflects the time, amount, and characteristics of bowel
movements. This chart can help the nurse prevent constipation and fecal
impaction by providing easily accessible data regarding bowel elimination.
Even older persons in the community can benefit from the use of an
elimination record that they can maintain themselves.
Chronic constipation that does not improve with the usual measures
may require medical evaluation, including anal, rectal, and sigmoid
examinations, to determine the presence of any underlying cause.
Flatulence
Flatulence, which is common in older adults, is caused by constipation,
irregular bowel movements, certain foods (e.g., the high-fiber foods
promoted for increased dietary intake in recent years), and poor
neuromuscular control of the anal sphincter. Achieving a regular bowel
pattern and avoiding flatus-producing foods may relieve this problem, as
may the administration of specific medications intended for this purpose.
Sitting upright after meals is helpful in allowing gas to rise to the fundus of
the stomach and be expelled.
Discomfort associated with the inability to expel flatus can occur
occasionally. Increased activity can provide relief, as may a knee–chest
position, if possible. A flatus bag consisting of a rectal tube with an
attached plastic bag that prevents the entrance of air into the rectum can be
beneficial.
Partial or complete impairment of flow of intestinal contents in the large
intestines most often occurs due to cancer of the colon; adhesions and
hernias are the primary cause of obstructions in the small intestine. Other
causes of blockage include diverticulitis, ulcerative colitis, hypokalemia,
vascular problems, and paralytic ileus, a mechanical obstruction that can
occur following surgery due to nerves being affected by the extended lack
of peristaltic activity.
Symptoms vary depending on the site and cause of the obstruction:
Small bowel obstruction causes upper and mid-abdominal pain in

rhythmic recurring waves related to the small intestine’s attempt to
push the contents through the obstruction. Vomiting occurs and may
bring some relief.
Obstructions occurring past the ileum cause abdominal distension so
severe that the raised diaphragm can inhibit respirations. Vomiting is
more severe than with small bowel blockages and initially is composed
of semidigested food and later contains bile and is more watery.
Obstruction of the colon causes lower abdominal pain, altered bowel
habits, distension, and a sensation of the need to defecate. Vomiting
usually does not occur until late, when the distension reaches the small
intestine.
CONSIDER THIS CASE

Mr. C is a 75-year-old participant in an
adult day care program. In interviewing him, you learn that he had a
cerebrovascular accident 2 years ago that left him with some right-sided
weakness. His medical record indicates that he also has a history of hiatal
hernia, depression, hypertension, and osteoarthritis. He is taking
antihypertensive, antidepressant, and nonsteroidal anti-inflammatory
drugs.
THINK CRITICALLY
1. What threats to gastrointestinal health exist for Mr. C?
2. What measures could be taken to reduce those threats?
The nurse should review symptoms thoroughly and note bowel sounds.
Bowel obstruction can cause high-pitched peristaltic rushes to be heard on
auscultation. If the obstruction has persisted for a long time or the bowel
has been significantly damaged, bowel sounds decrease and eventually are
absent.
Timely intervention is essential to prevent bowel strangulation and
serious complications. X-rays and blood evaluation typically are done to
determine the cause and extent of the problem. Intestinal intubation is the
major treatment and often helps to decompress the bowel and allow the
obstruction to be broken. If medical management is unsuccessful or if the
cause is due to vascular or mechanical obstructions, surgery is required. In
addition to supporting the medical or surgical treatment plan, nurses need to
promote the patient’s comfort and ensure that fluid and electrolyte balance
is restored and maintained.
Fecal Impaction
Prevention of constipation aids in avoiding fecal impaction. Observing the
frequency and character of bowel movements may aid in detecting the
development of an impaction; a bowel elimination record is essential for
older people in a hospital or nursing home for identifying alternations in
bowel elimination. Indications of a fecal impaction include the following:
Distended rectum
Abdominal and rectal discomfort
Oozing of fecal material around the impaction, often mistaken as
diarrhea
Palpable, hard fecal mass
Fever
Because policies may vary, nurses should review the permissive

procedures of their employing agency to ensure that removal of a fecal
impaction is an acceptable nursing action. An enema, usually oil retention,
may be prescribed to assist in the softening and elimination process.
Manual breaking and removal of feces with a lubricated gloved finger will
promote removal of the impaction. Sometimes, injecting 50 mL hydrogen
peroxide through a rectal tube will cause breakage of the impaction as the
hydrogen peroxide foams. Care should be taken not to traumatize or
overexert the patient during these procedures.
Fecal Incontinence
Involuntary defecation, fecal incontinence , refers to the inability to
voluntarily control the passage of stool. It is most often associated with
fecal impaction in older adults who are institutionalized or physically or
cognitively impaired. For this reason, the initial step is to assess for the
presence of an impaction. If an impaction is not present, the nurse must
assess for other causes. Possible causes of bowel incontinence include
decreased contractile strength, impaired automaticity of the puborectal and
external anal sphincter (secondary to age-related muscle weakness or injury
to the pudendal nerve), loss of cortical control, and reduced reservoir
capacity (secondary to surgical resection or the presence of a tumor).
Proctosigmoidoscopy, proctography, and anorectal manometry are among
the diagnostic tests used to evaluate this disorder. The cause of the
incontinence dictates the treatment approach, which could include bowel
retraining (NURSING CARE PLAN 18-2), drugs, surgery, or biofeedback.

THE OLDER ADULT WITH FECAL INCONTINENCE
Nursing Problem: Fecal incontinence
Acute Appendicitis
Although acute appendicitis does not occur frequently in older persons, it is
important to note that it may present with altered signs and symptoms if it
does occur. The severe pain that occurs in younger persons may be absent
in older adults, whose pain may be minimal and referred. Fever may be
minimal, and leukocytosis may be absent. These differences often cause a
delayed diagnosis. Prompt surgery will improve the patient’s prognosis.
Unfortunately, delayed or missed diagnosis and the inability to improve the
general status of the patient before this emergency surgery can lead to
greater complications and mortality in older persons with appendicitis.

Pancreatic cancer primarily affects older adults, peaking between ages 70
and 79 years, and is difficult to detect until it has reached an advanced
stage. Anorexia, weakness, weight loss, and wasting are generalized
symptoms easily attributed to other causes. Dyspepsia, belching, nausea,
vomiting, diarrhea, constipation, and obstructive jaundice may occur as
well. Fever may or may not be present. The person may experience
epigastric pain radiating to the back. This pain is relieved when the person
leans forward and is worsened when a recumbent position is assumed.
Surgery is performed to treat this problem. Unfortunately, the disease is
generally so advanced by the time diagnosis is made that the prognosis is
usually poor.

Cholelithiasis , the formation or presence of gallstones in the gallbladder,
increases with age and affects women more frequently than men. Pain,
often following meals, is the primary symptom. Treatment measures
include nonsurgical therapies, such as rotary lithotrite treatment and
extracorporeal shock wave lithotripsy, and the standard surgical procedures.
Obstruction, inflammation, and infection are potential outcomes of
gallstones and require monitoring.
Cancer of the gallbladder primarily affects older persons, especially
women. Fortunately, this disease does not occur frequently. Pain in the right
upper quadrant, anorexia, nausea, vomiting, weight loss, jaundice,
weakness, and constipation are the usual symptoms. Although surgery may
be performed, the prognosis for the patient with cancer of the gallbladder is
poor.
Association Between Oral Health and Frailty: A

Systematic Review of Longitudinal Studies
Source: Hakeem, F. F., Bernabe, E., & Sabbah, W. (2019). Gerodontology,
36(3), 205–215.
The status of one’s teeth and oral cavity in general can impact physical,
emotional, and social health. Because of this relationship, geriatric health
care professionals have traditionally viewed poor oral health as a cause of a
decline in health that could lead to frailty; however, evidence supporting
this view has been scarce. This study sought to find longitudinal studies that
could support the association between oral health and frailty in older adults.
The researchers found five longitudinal studies that explored the
relationship between oral health and frailty. Oral health indicators used
included number of teeth present, evidence of periodontal disease, ability to
bite and chew food, use of dentures, and presence of dry mouth, or oral
health problems. Frailty was measured using Fried’s frailty phenotype
criteria. The review showed significant relationships between oral health
indicators and frailty.
Frailty significantly alters the quality of life and functional ability of
older adults. Poor oral health is a cause of frailty that can be prevented.
Instructing older adults in good oral health practices and encouraging
regular dental examination are important measures that can be included in
routine nurse–patient contacts. Older adults who are unable to
independently provide their own oral hygiene should be assisted to ensure
their oral health is not threatened. Although this may seem like a basic
measure, encouraging—and, when necessary, providing—good oral
hygiene can significantly impact the health, function, and quality of life of
older adults.
PRACTICE REALITIES
A local church with a membership of more than 2,000 people has initiated a
health ministry program and surveyed their members to assess needs. One
of the findings of the survey was that less than 10% of the adults older than
60 years of age had ever had a colonoscopy. All of the respondents had
insurance that could cover the cost of the procedure so financial hardship
wasn’t an obstacle.
The church asks you to assist them in developing a campaign to encourage

colorectal screening.
What would you envision the components of this program to be?
What strategies could stimulate interest of the church members?

1. What age-related changes affect bowel elimination?
2. Describe the changes in dental care that have occurred since today’s
older adults were children and the way in which this will affect dental
health of future generations of older persons.
3. What preventive measures could you recommend to older adults to
promote bowel elimination?
4. What are some actions that a nursing home could take to assess the
presence of dysphagia and to monitor their residents for new or
worsening of dysphagia symptoms on an ongoing basis?

questions.
The nurse is completing a direct admission
assessment of an 80-year-old female client on a
telemetry unit.Nurse’s Notes
1300: The client is brought to the unit accompanied by her son directly
from her primary healthcare provider’s office. The client states that she
started feeling severe abdominal cramping in her lower abdomen that has
lasted for 3 days. She further indicates that the pain became unbearable
and sharp in nature, so she called her son and asked him to drive her to
her doctor’s office. During the office visit, she becomes diaphoretic,
starts to vomit, and begins to experience chest pain. The client reports
being otherwise healthy except for occasional heartburn spells that
started 6 months ago.
Her primary healthcare provider quickly decides to admit her to the
telemetry unit for an overnight observation. The admitting orders are as
follows: place on telemetry, protoxin 20 mg IV daily, and Tylenol 650
mg suppository every 6 hours as needed for pain. Labs ordered include
cardiac enzymes STAT and CBC (complete metabolic profile). Keep
patient NPO for stress test in the morning. Home medications include
calcium 2,000 mg/d and antacids over the counter. Client indicates that
she takes the antacids frequently for her heartburn and doubles the dose
of her calcium consumption because of occasional joint pain.
1500: The nurse notes that the client’s abdomen is distended and difficult
to palpate. Client indicates that she doesn’t remember the last time she
had a bowel movement but thinks it was sometime last week. Client
reports burning stomach pain and belching with frequent hiccups. Vital
signs: temperature 99.0°F oral, pulse 120, respirations 20, blood pressure
120/76, bedside blood glucose level 70 mg/dL, and pulse oximetry 99%
on room air. The client’s weight is 97 lb. She indicates that she has lost
15 lb within the last month; she has been eating less because it hurts to
chew. The nurse notes that the client’s teeth have various degrees of
erosion, abrasions of crown and root structure, and high prevalence of
tooth loss. Client indicates that she does not like drinking water but
drinks a nutritional shake that her primary healthcare provider ordered
because of her weight loss. Client is tentatively diagnosed with possible
myocardial infarction, gastroesophageal reflux disease (GERD), peptic
ulcer disease (PUD), and gastritis.
Chapter Summary
Although most of the gastrointestinal problems experienced by older adults
are not life threatening, they can significantly affect the quality of life and
health status of this population, thereby making their effective management
important. Some gastrointestinal conditions can be prevented by good
health practices, including regular oral hygiene, sound dietary practices,
regular bowel elimination, and prompt attention to symptoms.
Gastrointestinal symptoms, although common, can indicate serious
medical problems in older adults and need to be taken seriously. Conditions
such as xerostomia, dysphagia, hiatal hernia, esophageal cancer, peptic
ulcer, cholelithiasis, and cancer of the stomach, colon, and pancreas occur
with greater frequency in older adults. Diagnosis of these problems can be
difficult because of atypical symptomatology, self-medication that masks
symptoms, and easy confusion with disorders of other systems. Astute
questioning and alertness to subtle symptoms during the assessment can
help these conditions to be diagnosed and treated early.
Online Resources
American Dental Association
https://www.ada.org
Crohn’s & Colitis Foundation of America
https://www.crohnscolitisfoundation.org
National Institute of Dental and Craniofacial Research
https://www.nidcr.nih.gov
United Ostomy Associations of America, Inc.
https://www.uoa.org
References
American Cancer Society. (2020). Key statistics about stomach cancer. Retrieved April 1, 2020 from
https://www.cancer.org/cancer/stomach-cancer/about/key-statistics.html
Graham, D. Y., & Tan, M. C. (2020). No Barrett’s—No cancer: A proposed new paradigm for
prevention of esophageal adenocarcinoma. Journal of Clinical Gastroenterology , 54 (2), 136–
143.
http://thepoint.lww.com/Eliopoulos10e to access the recommended
CHAPTER 19
Urinary Elimination
Chapter Outline
Effects of Aging on Urinary Elimination
Urinary System Health Promotion
Selected Urinary Conditions
Bladder Cancer
Renal Calculi
Glomerulonephritis
General Nursing Considerations for Urinary Conditions
LEARNING OBJECTIVES
1. Describe age-related changes that affect urinary elimination.

2. List measures that promote urinary system health.
3. Outline factors to consider in assessing the urinary system.
4. Describe the incidence, symptoms, and management of selected
urinary conditions.
5. Outline a care plan for the patient who is incontinent of urine.
TERMS TO KNOW
Established incontinenceinvoluntary loss of urine that can have an
abrupt or sudden onset and is chronic
Functional incontinenceloss of voluntary control of urine due to
disabilities that prevent independent toileting, sedation, inaccessible
bathroom, medications that impair cognition, or any other factor
interfering with the ability to reach a bathroom
Glomerulonephritiscondition in which there is inflammation of the
glomeruli, which filter blood as it passes through the kidneys
Mixed incontinenceinvoluntary loss of urine due to a combination of
factors
Neurogenic (reflex) incontinenceloss of control of voiding due to
inability to sense the urge to void or control urine flow
Nocturiavoiding at least once during the night
Overflow incontinenceinvoluntary loss of urine due to an excessive
accumulation of urine in the bladder
Stress incontinenceinvoluntary loss of urine when pressure is placed on
the pelvic floor (e.g., from laughing, sneezing, or coughing)
Transient incontinenceinvoluntary loss of urine that is acute in onset and
usually reversible
Urgency incontinenceinvoluntary loss of urine due to irritation or spasms
of the bladder wall that cause a sudden elimination of urine
Urinary incontinenceinvoluntary loss of urine
Urinary problems, although bothersome, frequent, and potentially life

threatening, are disorders not easily discussed by older adults. Some feel
embarrassment or believe it is inappropriate to talk about these problems,
while other individuals may accept symptoms of urinary disorders as a
normal part of aging. These factors often delay early detection and
treatment. Untreated, these problems can jeopardize total body health and
affect psychosocial well-being. Nurses are in ideal positions to develop
close relationships with older patients, which can help patients to more
comfortably discuss problems of the urinary tract. By demonstrating
sensitivity, acceptance, and understanding of patients’ problems, nurses can
facilitate prompt, appropriate intervention.
EFFECTS OF AGING ON URINARY

ELIMINATION
Age-related changes in the urinary tract may cause various elimination
problems. One of the greatest annoyances is urinary frequency, caused by
hypertrophy of the bladder muscle and thickening of the bladder, which
decreases the ability of the bladder to expand and reduces storage capacity.
In addition to frequency during the day, nighttime urinary frequency (
nocturia ) can be a problem. Often, kidney circulation improves when the
person assumes a recumbent position, so voiding may be required a few
hours after the individual lies down and at other times during the night.
Age-related changes in cortical control of micturition also contribute to
nocturia; this problem, along with incontinence (which is not a normal
consequence of aging), can be noted in persons with dementia or other
conditions affecting the cerebral cortex. Nurses should advise older adults
and their caregivers that long-acting diuretics, such as the thiazides, even
when administered in the morning, can also cause nocturia. If multiple
episodes of nocturia occur, medical evaluation may be warranted to ensure
that no urinary tract problem is present.
Inefficient neurologic control of bladder emptying and weaker bladder
muscles can promote the retention of large volumes of urine. In women, the
most common cause of urinary retention is a fecal impaction; prostatic
hypertrophy, present to some degree in most older men, is the primary
cause in men. Symptoms of retention include urinary frequency, straining,
dribbling, palpable bladder, and the sensation that the bladder has not been
emptied. Retention can predispose older individuals to the development of
urinary tract infections (UTIs).
The filtration efficiency of the kidneys decreases with age, affecting the
body’s ability to eliminate drugs. The nurse should observe the patient for
signs of adverse drug reactions resulting from an accumulation of toxic
levels of medications. Higher blood urea nitrogen levels may occur due to
reduced renal function, causing lethargy, confusion, headache, drowsiness,
and other symptoms. Decreased tubular function may cause problems in the
concentration of urine. Reduced ability to concentrate and dilute urine in
response to water or sodium excess or depletion occurs. An increase in the
renal threshold for glucose is a serious concern, because older individuals
can be hyperglycemic without evidence of glycosuria. False-negative
results in diabetic urine testing can occur for this reason.
KEY CONCEPT
Changes in the renal threshold for glucose can cause some older adults to
be hyperglycemic without having any evidence of glycosuria.
The inability to control the elimination of urine (i.e., incontinence) is

not a normal occurrence with advanced age; however, age-related changes
increase the risk of this problem. Incontinence reflects a physical or mental
disorder and demands a thorough evaluation. Some stress incontinence may
be present, particularly in women who have had multiple pregnancies or in
persons who postpone voiding after they sense the urge. More information
on incontinence is discussed later in the chapter.
URINARY SYSTEM HEALTH

PROMOTION
Basic health practices, which are easily incorporated into the daily
schedule, can prevent a variety of urinary tract problems. For instance, a
good fluid intake can reduce the amount of bacteria in the bladder. Acidic
urine, beneficial in preventing infection, can be enhanced by the intake of
vitamin C and foods such as cranberries, prunes, plums, eggs, cheese,
yogurt, fish, and grains. Catheterization significantly increases the risk of
infection and should be avoided. Activity can eliminate urinary stasis, and
frequent toileting can prevent urinary retention. The nurse can teach older
adults specific efforts to enhance voiding and prevent retention, including
the following:
Voiding in upright position

Massaging bladder area
Rocking back and forth
Running water
Soaking hands in warm water
The reduced bladder capacity of older adults should be kept in mind
when individuals who are unable to ambulate independently are placed in
wheelchairs; they will not be able to sit all day without needing to void, and
unnecessary incontinence may result if toileting assistance is not provided.
Trips and activities should be planned to allow bathroom breaks at frequent
intervals.
For older adults experiencing nocturia, nurses can implement measures
to promote patients’ safety. Because older adults’ increased threshold for
light perception makes night vision difficult, nocturia could predispose
them to accidents when attempting to walk to the bathroom in the dark.
Nightlights should be used to improve visibility during trips to the
bathroom, and any clutter or environmental hazards that could cause a fall
should be removed. Reducing fluids immediately before bedtime may help,
although they should not be significantly restricted.
A complete history and examination are essential to pinpoint specific
areas that require further investigation; however, obtaining data about
urinary function and problems can be difficult. Because older persons may
feel embarrassment about discussing these problems, the nurse should set a
comfortable tone and display sensitivity during the assessment to facilitate
good data collection. Assessment Guide 19-1 describes some of the areas to
include in assessing the urinary system; Table 19-1 outlines some of the
nursing problems that could be identified.
TABLE 19-1 Nursing Problems Associated With Aging and

Urinary Conditions
URINARY FUNCTION
INTERVIEW
Ask questions pertaining to the following:
Frequency of voiding. “How often do you need to urinate during the

day and during the night? Has there been any recent change in that
pattern?”
Continence. “Do you ever lose control of your urine? Do you
experience a steady stream of urine dribbling at all times or at certain
times? Is urine released when you cough or sneeze? How soon do
you need to toilet after getting the urge to void before you lose
control?”
Retention. “Do you ever feel that you have not fully emptied your
bladder after you have voided? Do you have a sense of fullness in
your bladder after voiding?”
Pain. “Does it burn when you void? Do you experience pain in your
lower abdomen or anywhere else? Is there any tenderness,
discomfort, itching, or pain anywhere along your genital area?”
Urine. “Have you ever seen crystals or particles in your urine? Is
your urine ever pink, bloody, or discolored? Is it as clear as tap water
or as dark as rusty water? Does your urine ever have a strong odor? If
so, what is that odor like?”
Medications. “Do you take any prescription or nonprescription
medications? If so, which ones? Do you use any herbal
preparations?”
Inspect, percuss, and palpate the abdomen for bladder fullness, pain,
or abnormalities.
Test women for stress incontinence by doing the following:
Have the patient drink at least one full glass of fluid and wait
until she senses fullness of the bladder.
Instruct the patient to stand. If this is not possible, have her sit as
upright as possible.
Ask the patient to hold a 4 × 4 gauze at her perineum.
Instruct the patient to cough vigorously.
The test is negative if no leakage or leakage of only a few drops
occurs. If residual urine is a problem, a postvoid residual may be
ordered in which the patient is catheterized within 15 minutes of
voiding to determine the volume of urine remaining in the
bladder.
If incontinence is present, refer the patient for a comprehensive
evaluation; it can prove useful to maintain a record or have the
patient maintain a diary of each occurrence of incontinence and
factors associated with these incidents.
EXAMINATION OF URINE SAMPLE

A urinalysis can provide basic information about this system. The specific
gravity should range from 1.005 to 1.025 and the pH from 4.6 to 8.
Although alkaline urine is most often associated with infections, it can be
present if the specimen has been sitting for a few hours. Normally the
urine should be free of glucose and protein, but renal changes in the older
adult cause proteinuria and glycosuria to be less reliable findings.
Note the color of the urine sample. Examination of the urine’s color
can yield insight into the presence of health problems. Dark colors can
indicate increased urine concentration. Red or rust color usually is
associated with the presence of blood. Yellow-brown or green-brown color
can be caused by an obstructed bile duct or jaundice. Orange urine results
from the presence of bile or the ingestion of phenazopyridine. Very dark
brown urine is associated with hematuria or carcinoma.
Also note the urine sample’s odor. A faint aromatic odor of the urine is
normal. Strong odor can indicate concentrated urine associated with
dehydration. Ammonia-like odor can accompany infections.
SELECTED URINARY CONDITIONS

UTIs are the most common infection of older adults and increase in
prevalence with age. Although UTIs occur more frequently in women than
in men at younger ages, the gap between the sexes narrows in late life,
which is attributable to reduced sexual intercourse in women and a higher
incidence of bladder outlet obstruction secondary to benign prostatic
hyperplasia in men. Organisms primarily responsible for UTIs are
Escherichia coli in women and Proteus species in men. The presence of any
foreign body in the urinary tract or anything that slows or obstructs the flow
of urine (e.g., immobilization, urethral strictures, neoplasms, or a clogged
indwelling catheter) predisposes the individual to these infections. UTIs can
result from poor hygienic practices, improper cleansing after bowel
elimination, a predisposition created by low fluid intake and excessive fluid
loss, and hormonal changes, which reduce the body’s resistance. Persons in
a debilitated state or who have neurogenic bladders, arteriosclerosis, or
diabetes also have a high risk of developing UTIs. Of major consideration
are catheter-associated UTIs, which are the single most common type of
health care–associated infection.
KEY CONCEPT
UTIs can result from poor hygienic practices, prostate problems,
catheterization, dehydration, diabetes, arteriosclerosis, neurogenic
bladders, and general debilitated states.
The gerontological nurse should be alert to the signs and symptoms of

UTIs. Early indicators include burning, urgency, and fever. Some older
adults develop incontinence and delirium with UTIs. Awareness of the
patient’s normal body temperature helps the nurse recognize the presence of
fever—for instance, 99°F (37°C) in a patient whose normal temperature is
96.8°F (35°C). Some urologists believe that many UTIs in older adults
seem asymptomatic due to lack of awareness of elevations in normal
temperature from the baseline norm. The nurse can significantly facilitate
diagnosis by informing the physician of temperature increases from the
patient’s normal level. Bacteriuria greater than 105 CFU/mL confirms the
diagnosis of UTI. As a UTI progresses, retention, incontinence, and
hematuria may occur.
Treatment aims to establish adequate urinary drainage and control the
infection through antibiotic therapy. The nurse should carefully note the
patient’s fluid intake and output. Forcing fluids is advisable, provided that
the patient’s cardiac status does not contraindicate this action. Observation
for new symptoms, bladder distention, skin irritation, and other unusual
signs should continue as the patient recovers.
Severe UTIs leading to septicemia occur more frequently among older
persons than among the young, as do recurrent UTIs. Urosepsis (septicemia
secondary to UTI) is a common complication of persons with indwelling
catheters, so selective use of catheters is important.
Asymptomatic bacteriuria is a common finding in older adults and is
usually not treated, although it is important to assess underlying factors that
could contribute to this condition.
Cranberry juice has long been promoted as a means to reduce UTIs, and
there is some evidence to support this belief (Liu et al., 2020). The
gerontological nurse may want to promote the daily inclusion of cranberry
juice in the diet of older adults. (It may be best to use forms such as
capsules that have no sugar added to avoid the high sugar content of some
commercial brands; these capsules and other freeze-dried forms of
cranberry juice are available at most health food stores.)
An important measure to assist in the prevention of UTIs is to avoid the
use of urinary catheters. Nurses should question the rationale for orders for
indwelling catheters and consider other options. The convenience of staff
(e.g., reducing the need to change soiled linens or to toilet a person) is not
justification for inserting an indwelling catheter and exposing the individual
to the risk of UTI. Early removal of the catheter should be encouraged as
this has been found to reduce the risk of UTI.
Prostatitis is the most common UTI among older men. Although
nonbacterial prostatitis is responsible for some cases, most infections are
bacterial in origin. Acute bacterial prostatitis is characterized by the
systemic symptoms of fever, chills, and malaise, whereas these symptoms
are uncommon with chronic bacterial prostatitis. Both types will present
urinary symptoms of frequency, nocturia, dysuria, and varying degrees of
bladder obstruction secondary to an edematous, enlarged prostate, as well as
lower back and perineal pain. A simple urinalysis usually can identify the
pathogen responsible for acute bacterial prostatitis; with the chronic form, a
special process may be used to collect a clean-catch urine sample, with
prostatic secretions obtained by massaging the prostate during the
procedure. Acute prostatitis usually responds well to antibiotic therapy;
chronic prostatitis responds less well to antibiotics and is more difficult to
treat.

Yoder • Part 3
Recall from Chapters 5 and 14 Sherman
“Red” Yoder, an 80-year-old male with insulin-dependent diabetes and a
foot wound. During the assessment, the home health nurse discovers that
he is having urgency incontinence and often avoids fluids, especially
before driving 20 miles to have coffee with friends. How can urinary
incontinence affect Red’s quality of life? What age-related changes and
conditions can increase the potential for urinary incontinence? What
further assessments and interventions can be incorporated in the nursing
plan of care to promote urinary wellness?
A common and bothersome disorder of older adults that requires skillful
nursing attention is the involuntary loss of urine or urinary incontinence .
Studies have shown that urinary incontinence is present in more than half of
the nursing home population; among community-based older adults, 25% to
45% experience some degree of urinary incontinence with the incidence
higher with advanced age (Milsom & Gyhagen, 2018).

The most important goal to facilitate physiologic balance of an older client
who has risk of injury related to urinary incontinence is to be free from
falls related to escaped urine (e.g., falls on urine puddles).
Incontinence can be transient or established. Transient incontinence is

acute and reversible and can be caused by infections, delirium, medication
reactions, excessive urine production, fecal impaction, mood disorders, or
the inability to reach a commode or urinal (e.g., being on bed rest,
restrained, and dependent). The onset is abrupt and treatment of the
underlying cause can reverse the problem. Established incontinence is
chronic and persistent with either an abrupt or gradual onset. The following
are various types of established incontinence:
Stress incontinence: caused by weak supporting pelvic muscles. When

intra-abdominal pressure is placed on the pelvic floor (e.g., from
laughing, sneezing, or coughing), urine is involuntarily lost. Obesity
contributes to this problem.
Urgency incontinence: caused by UTI, enlargement of the prostate,
diverticulitis, or pelvic or bladder tumors. Irritation or spasms of the
bladder wall cause a sudden elimination of urine.
Overflow incontinence: associated with bladder neck obstructions and
medications (e.g., adrenergics, anticholinergics, and calcium channel
blockers). Bladder muscles fail to contract or periurethral muscles do
not relax, leading to an excessive accumulation of urine in the bladder.
Neurogenic (reflex) incontinence: arising from cerebral cortex lesions,
multiple sclerosis, and other disturbances along the neural pathway.
There is an inability to sense the urge to void or control urine flow.
Functional incontinence: caused by dementia, disabilities that prevent
independent toileting, sedation, inaccessible bathroom, medications
that impair cognition, or any other factor interfering with the ability to
reach a bathroom.
Mixed incontinence: can be due to a combination of these factors.
Nurses should not assume that individuals with incontinence, even

long-term incontinence, have necessarily had this problem identified and
evaluated. Embarrassment in discussing this disorder or the belief that
incontinence is a normal outcome of aging can lead to unreported
incontinence. This reinforces the importance of questioning about
incontinence during every routine assessment. In addition to referring the
patient for a comprehensive medical evaluation, nurses can help identify the
cause and determine appropriate treatment measures through the process of
nursing assessment. Box 19-1 lists some of the factors to consider in
assessing the incontinent individual.
BOX 19-1 Factors to Assess in the Patient Who

Is Incontinent of Urine
Medical history: Note diagnoses that could contribute to
incontinence, such as delirium, dementia, cerebrovascular accident,
diabetes mellitus, congestive heart failure, UTI.
Medications: Review all prescription and nonprescription drugs
used for those that can affect continence, such as diuretics,
antianxiety agents, antipsychotics, antidepressants, sedatives,
narcotics, antiparkinsonian agents, antispasmodics, antihistamines,
calcium channel blockers, and alpha-blockers and alpha-stimulants.
Functional status: Assess activities of daily living; note
impairments; ask about recent changes in function; determine
degree of dependency on others for mobility, transfers, toileting.
Cognition: Test cognitive function; review symptoms such as
depression, hallucinations; ask about recent changes in mood or
intellectual function.
Neuromuscular function in lower extremities: Test patient’s
ability to keep leg lifted against your efforts to gently push it down;
touch various areas along both legs with pin point and smooth side
of safety pin to determine patient’s ability to detect and differentiate
sensations.
Urinary control and retention: Test for stress incontinence in
women; determine postvoid residual.
Bladder fullness and pain: Inspect, percuss, and palpate the
bladder for distension, discomfort, and abnormalities.
Elimination pattern: Record bladder elimination patterns and
associated factors for several days; enquire about changes to
elimination pattern; note frequency, pattern, amount, and
relationship to other factors.
Fecal impaction: Palpate the rectum for the presence of fecal
impaction (unless contraindicated).
Symptoms: Ask about urgency, burning, vaginal itching, pain,
pressure in bladder area, fever.
Diet: Assess intake of potential bladder irritants: caffeine, alcohol,
citrus fruits/juices, tomatoes, spicy foods, artificial sweeteners.
Reactions to incontinence: Explore how incontinence has affected
activities, lifestyle, self-concept; determine patient’s appraisal of
problem.
COMMUNICATION TIP
Due to embarrassment or the misconception that it is normal, older
adults may not mention that they experience urinary incontinence.
Skillful questioning can aid in identifying that the problem exists.
Questions such as “Do you ever leak or lose control of your urine?”
and “Do you have problems making it to the bathroom in time?” can
help to disclose that incontinence exists. When positive responses are
given, ask about when the problem began, if there was anything new
that occurred at that time (e.g., new or changed prescription, diet
change, relocation to a new living environment), how it is managed,
and how it may be affecting the person’s life (e.g., reduced
socialization, need to wear protective briefs, reluctance to engage in
sex). Discussing the incontinence in a matter-of-fact way in a private
setting can promote the individual’s openness in discussing the
problem.
The initial goal for incontinent individuals is to identify the cause of

incontinence; thereafter, treatment goals are developed based on the
underlying cause. Kegel exercises (Box 19-2), biofeedback, and the use of a
pessary and medications (e.g., estrogen or anticholinergics) may be useful
for the improvement of stress incontinence; in some circumstances, surgery
may be warranted. Urgency incontinence can be aided by adherence to a
toileting schedule, Kegel exercises, biofeedback, and medications (e.g.,
anticholinergics or adrenergic antagonists). Although Kegel exercises are
frequently recommended for stress incontinence , studies have shown that
there is a risk that women may not do them correctly or consistently, so
careful instruction is needed (Nguyen, Armstrong, Wieslander, & Tarnay,
2019). Overflow incontinence may benefit from adherence to a toileting
schedule, the use of the Crede’s method, intermittent catheterization, and
medications (e.g., parasympathomimetics). Interventions to assist with
functional incontinence could range from improvement of mobility to
provision of a bedside commode. NURSING CARE PLAN 19-1 presents a
sample care plan for the older adult with urinary incontinence.
BOX 19-2 Kegel Exercises

Kegel exercises are an approach to strengthening the pelvic floor
muscles, which can lead to an improvement in control over urine
incontinence. To achieve benefit, the woman must be able to perform the
exercises correctly and consistently. Nurses can give the following basic
instructions to women.
FIND THE MUSCLES INVOLVED IN THE EXERCISES
You first need to identify the pelvic floor muscles that are involved in the
exercises. To do this, stop the flow of urine while voiding and notice
how the muscles are tightening in the vaginal area and the pelvic floor is
lifting. Another approach is to insert a finger in your vagina and tighten
your muscles around your finger. Notice the vagina tightening and the
pelvic floor lifting. Stop and start the urinary flow several times until
you identify the muscles and understand the muscle movements.
PRACTICE THE EXERCISES
Void prior to starting the exercises. Get in a sitting or standing position
and tighten the pelvic floor muscles.
Be sure not to tighten the muscles of the abdomen, buttocks, or thighs
but just the pelvic muscles. At first, try to keep the muscles tightened for
about 5 seconds, several times in a row. Gradually increase the time the
muscles are tightened to 10 seconds with about 10 seconds of muscle
relaxation in between flexing.
PERFORM THE EXERCISES
Once you are able to hold the muscles tight for 10 seconds, perform a set
of 10 exercises in a row. Repeat these several times throughout the day,
every day. Results should be noted in 2 to 3 months. After improvement
in incontinence is obtained, it is helpful to continue doing Kegel
exercises to maintain the muscle strength. Even if the incontinence is not
completely eliminated, its progression can be slowed by doing these
exercises.

THE OLDER ADULT WITH URINARY INCONTINENCE
Nursing Problem: Urinary incontinence
Nursing Problem: Risk of skin breakdown related to incontinence
Nursing Problem: Potential for injury related to incontinence

Nursing Problem: Potential for social isolation and negative self-
concept
KEY CONCEPT
Nurses cannot assume that people with long-standing incontinence have
received a comprehensive evaluation of this problem. A careful review
of the medical history and interview with the patient are important to
determine whether diagnostic testing has been done.
Inconsistency on the part of the nursing staff is destructive to the

progress of patients and threatens their efforts to regain bladder control.
Conversely, positive reinforcement and encouragement are most beneficial
to the patient during this difficult program. Indwelling catheters should be
used only in special circumstances and certainly never for the convenience
of staff. UTIs are the most common type of health care–associated infection
(Medina & Castillo-Pino, 2019). In addition, the risk of developing urinary
calculi is high when indwelling catheters are present.
CONSIDER THIS CASE
Eighty-six–year-old Mr. E lives with his

daughter and her family. His bedroom is on the first floor of their two-
story home with a bathroom a short distance from his room. The family
members pass by Mr. E’s bedroom on a regular basis and have noticed a
strong urine odor coming from the room. Mr. E has no cognitive
impairments, fulfills his activities of daily living independently, and, as
has always been his pattern, conducts himself in a proper manner. Mr. E
has never mentioned any problem with elimination and, because he
launders his own linens and takes care of his own room, the family cannot
determine if he is wetting the bed.
THINK CRITICALLY
1. What are some of the challenges of this situation?
2. What advice could you offer the family in approaching this

issue with Mr. E?
Bladder Cancer
The incidence of bladder cancer increases with age. According to the
American Cancer Society (2020), 90% of the cases of bladder cancer are in
people over age 55 years and older men have more than three times the rate
of older women. Chronic irritation of the bladder, exposure to dyes, and
cigarette smoking—all avoidable factors—are among the risk factors
associated with bladder tumors. Some of the symptoms resemble those of a
bladder infection, such as frequency, urgency, and dysuria. A painless
hematuria is the primary sign and characterizes cancer of the bladder.
Standard diagnostic measures for this disease are used with the aged
patient, including cystoscopic examination.
Treatment for bladder cancer can include surgery, radiation,
immunotherapy, or chemotherapy, depending on the extent and location of
the lesion. The nurse should use the nursing measures described in
medical–surgical nursing literature. Observation for signs indicating
metastasis, such as pelvic or back pain, is part of the nursing care for
patients with bladder cancer.
Renal Calculi
Renal calculi occur most frequently in middle-aged adults. In older adults,
the formation of stones can result from immobilization, infection, changes
in the pH or concentration of urine, chronic diarrhea, dehydration, excessive
elimination of uric acid, and hypercalcemia. Pain, hematuria, and symptoms
of UTI are associated with this problem, and gastrointestinal upset may also
occur. Standard diagnostic and treatment measures are used for the aged,
and the nurse can assist by preventing urinary stasis, providing ample
fluids, and facilitating prompt treatment of UTIs.
Glomerulonephritis
Most frequently, chronic glomerulonephritis already exists in older
persons who develop an acute condition. The symptoms of this disease may
be so subtle and nonspecific that they are initially unnoticed. Clinical
manifestations include fever, fatigue, nausea, vomiting, anorexia,
abdominal pain, anemia, edema, arthralgias, elevated blood pressure, and an
increased sedimentation rate. Oliguria may occur, as can moderate
proteinuria and hematuria. Headache, convulsions, paralysis, aphasia, coma,
and an altered mental status may be consequences of cerebral edema
associated with this disease.
Diagnostic and treatment measures do not differ significantly from
those used for the young. Antibiotics, a restricted sodium and protein diet,
and close attention to fluid intake and output are basic parts of the treatment
plan. If older adults are receiving digitalis, diuretics, or antihypertensive
drugs, close observation for cumulative toxic effects resulting from
compromised kidney function must be maintained. The patient should be
evaluated periodically after the acute illness is resolved for exacerbations of
chronic glomerulonephritis and signs of renal failure.
GENERAL NURSING
CONSIDERATIONS FOR URINARY
CONDITIONS
Nurses need sensitivity in dealing with patients’ urinary problems. In
addition to being areas that are uncomfortable for discussion for some
persons, these disorders may raise fears and anxieties that tales of becoming
incontinent in old age perhaps are valid. Realistic explanations and a
committed effort to correcting these disorders are vital. All levels of staff
need to remember the importance of discretion and dignity in managing
these problems. Staff members should not check to see if a patient’s pants
are wet in front of others, allow someone to sit on a bedside commode in a
hallway, bring in a group of students without the patient’s permission to
observe a catheterization, or scold the patient for having an accident in bed.
Every effort should be made to minimize embarrassment and promote a
positive self-concept.

Living With Urinary Incontinence: Potential
Risks of Women’s Health? A Qualitative Study on
the Perspectives of Female Patients Seeking Care
for the First Time in a Specialized Center
Source: Pintos-Diaz, M. Z., Alonso-Blanco, C., Paras-Bravo, P.,
Fernandez-de-las-Penas, C., Paz-Zulueta, M., Fradejas-Sastre, V., &
Palacios-Cena, D. (2019). International Journal of Research in Public
Health, 16(19). Published online at https://www.mdpi.com/1660-
4601/16/19/3781.
As they age, women are at risk for urinary incontinence. To many, this
is a complex problem that affects every aspect of their health and well-
being: physical, emotional, and social. This qualitative exploratory and
descriptive study sought to gain insights into the experiences women who
had urinary incontinence. The women selected to participate in the study
were those who were seeking help for the first time at a urinary
incontinence center.
The women who participated in the study were interviewed and asked
to describe in as much detail as possible their experience with urinary
incontinence. They also were asked to write letters that described how their
incontinence affected their daily life; these were collected during the
interviews.
Information gathered from the women showed that their urinary
incontinence had a major impact on their lives. All claimed they had not
heard about urinary incontinence prior to experiencing it and that there was
not ample information about it available to them. Most described the
incontinence as making them feel unclean, insecure, stressed,
uncomfortable, and not in control. Some shared that they avoided travelling
and limited their social activities. A negative perception of the pelvic region
was reported by some.
Although urinary incontinence can be a common problem among older
adults, it may be a condition that patients have never heard about before or
carry misconceptions about. As an important first step, the nurse needs to
assess knowledge about the condition and provide relevant education. The
nurse should allocate time and encourage patients to express their feelings,
perceptions, and concerns about their incontinence. Providing education
and training on measures that can help manage urinary incontinence and
strategies for coping are important parts of the care plan. Because some
older adults may believe that urinary incontinence is normal as one ages,
they might not bring it up without being prompted, so asking specific
questions about it is an important part of the basic assessment of every older
adult. If there is a finding of incontinence, the nurse should refer patients
for evaluation to determine if the problem can be corrected. The nurse
should also provide education as to how it can be managed.
PRACTICE REALITIES
Nurse Adams works part-time in a 25-bed assisted living community.
Typically, she works the evening shift but has agreed to relieve a coworker
on the day shift for the weekend. On both days, Nurse Adams notices a
significant urine odor when she enters the building in the morning. After the
residents bathe and dress and their linens are changed, the odor is gone for
the remainder of the shift. In reviewing the residents’ records, she finds that
only two residents wear adult incontinence briefs for occasional urinary
incontinence. Based on the strong odor she detected, Nurse Adams suspects
there are additional residents with incontinence problems that are more than
occasional.
What steps can Nurse Adams take to address her suspicion?

1. What factors should be reviewed when assessing urinary incontinence,
and what barriers could arise in reviewing them and obtaining accurate
answers from older adults?
2. What can be done to reduce each of the major causes of urinary
incontinence in older adults?
3. What actions could be taken to promote a positive self-concept of an
individual with urinary incontinence?
4. Identify resources in your community to assist patients with
incontinence or cancer of the urinary system.

questions.
Two days ago, a 55-year-old female was admitted to the intensive care
unit (ICU) with a diagnosis of hyperglycemia based on a serum glucose
level of 320 mg/dL. Today she is being transferred to a medical–surgical
unit.
Nurse’s Notes
1300: The nurse conducting the transfer assessment notes the following
vital signs: temperature 99.6°F oral (37.5°C), heart rate 84, respiratory
rate 18, blood pressure 112/72, pulse oximetry 99% room air, bedside
glucose level 105 mg/dL. Client is alert to place, person, and time. The
nurse’s notes from admission indicate that the client has a history of type
2 diabetes without any comorbidities.
1445: While using the restroom, the client calls out for the nurse. The
nurse finds the client in tears and holding her lower back. She reports a
severe burning pain when she voided. The nurse notes that the client’s
urine color is dark brown, cloudy with a distinctive smell. The client
indicates that although she still has a strong urge to urinate, she cannot
now void. The nurse places a call to the physician on call.
Chapter Summary
Urinary tract problems increase in incidence with age. Bladder changes
contribute to urinary frequency and nocturia, whereas prostatic hypertrophy
and fecal impactions can lead to urinary retention.
Due to the embarrassment of discussing urinary problems or the
misconception that problems like incontinence are normal in late life, older
persons may not contribute a history of these problems. Astute, sensitive
interviews that explore these problems are beneficial.
Although not a normal outcome of aging, urinary incontinence is
present among more than half of institutionalized older adults and more
than 25% of those who live in the community. There are several types of
incontinence; therefore, to establish a realistic care plan, a thorough
evaluation is essential. Even if incontinence has been a long-standing
problem, the history should be reviewed to determine if a complete
evaluation was performed.
Most bladder cancers occur in older adults. Symptoms can resemble
those associated with UTI; however, a painless hematuria is the primary
sign that should be noted. Renal calculi can also cause hematuria, but pain
and UTI symptoms occur as well. Glomerulonephritis may exist in older
persons without being diagnosed because of its nonspecific symptoms. Due
to the compromised renal function that can occur in patients with
glomerulonephritis, the risk of toxicity from certain drugs is increased,
warranting close monitoring of the individual.
Online Resources
American Urologic Association
https://www.auanet.org
National Association for Continence
https://www.nafc.org
National Institute of Diabetes and Digestive and Kidney Diseases,
National Kidney and Urologic Diseases Information Clearinghouse
https://www.niddk.nih.gov
Simon Foundation for Continence
https://www.simonfoundation.org
Society of Urologic Nurses and Associates
https://www.suna.org
Urology Care Foundation
https://www.urologyhealth.org
References
American Cancer Society. (2020). Key statistics for bladder cancer. Retrieved April 2, 2020 from
https://www.cancer.org/cancer/bladdercancer/detailedguide/bladder-cancer-key-statistics
Legendre, G., Fritel, X., Panjo, H., Zins, M., & Ringa, V. (2020). Incidence and remission of stress,
urge, and mixed urinary incontinence in midlife and older women: A longitudinal cohort study.
Neurourology and Urodynamics, 39 (2), 650–657.
Liu, H., Garrett, T. J., Su, Z., Khoo, C., Zhao, S., & Gu, L. (2020). Modifications of the urinary
metabolome in young women after cranberry juice consumption were revealed using the
UHPLC-Q-orbitrap) MRMS-based metabolomics approach. Food & Function, 11 (3), 2466–
2476.
Medina, M., & Castillo-Pino, E. (2019). An introduction to the epidemiology and burden of urinary
tract infections. Therapeutic Advances in Urology. Retrieved April 1, 2020 from
Milsom, I., & Gyhagen, M. (2018). The prevalence of urinary incontinence. Climacteric, 22 (3), 1–6.
Nguyen, M. L. T., Armstrong, A. A., Wieslander, C. K., & Tarnay, C. M. (2019). Now anyone can
Kegel: One-time office teaching of pelvic floor muscle exercises. Female Pelvic Medicine &
Reconstructive Surgery, 25 (2), 149–153.
CHAPTER 20
Reproductive System Health
Chapter Outline
Effects of Aging on the Reproductive System
Reproductive System Health Promotion
Selected Reproductive System Conditions
LEARNING OBJECTIVES
1. List changes to the male and female reproductive systems that occur
with age.
2. Describe measures to promote reproductive system health in older
adults.
3. Outline factors to consider in assessing reproductive system health in
older adults.
4. Describe the symptoms and management of selected disorders of the
reproductive system.
5. Outline care plan measures for the patient who has had prostate
surgery.
TERMS TO KNOW
Benign prostatic hyperplasianonmalignant enlargement of the prostate
gland that commonly occurs with age
Dyspareuniapainful intercourse
Erectile dysfunctionimpotence problems in achieving or sustaining an
erection for intercourse
As with urinary problems discussed in the last chapter, reproductive system
problems may be difficult topics for older adults to discuss. However, it is
important for older adults to consider their reproductive systems when
thinking of their overall health. In addition to preventing and detecting
serious problems such as cancer and sexually transmitted diseases,
understanding health practices related to the reproductive system can
promote satisfying sexual activity for older persons, yielding multiple
benefits. Gerontological nurses can play an important role in educating
older adults about changes that occur with aging and about important health
promotion measures to prevent or identify potentially serious reproductive
system problems.
EFFECTS OF AGING ON THE

REPRODUCTIVE SYSTEM
There are several changes in the female reproductive system that increase
the risk of uncomfortable conditions and interfere with satisfying sexual
experiences. Hormonal changes cause the vulva to atrophy. There is a
flattening of the labia and loss of subcutaneous fat and hair. The vaginal
epithelium becomes thin, and the vaginal environment is drier and more
alkaline; these changes can cause intercourse to be uncomfortable for older
women, although orgasms and satisfying sexual experiences are normally
possible. The cervix, uterus, fallopian tubes, and ovaries atrophy. The uterus
and ovaries also decrease in size; therefore, they may not be palpable during
the physical examination. The endometrium continues to respond to
hormonal stimulation. The fallopian tubes also undergo shortening and
straightening. The breasts sag and are less firm with age due to the
replacement of mammary glands by fat tissue after menopause. Some
retraction of the nipples may occur as a result of shrinkage and fibrotic
changes. Firm linear strands may develop on the breasts from fibrosis and
calcification of the terminal ducts.
The genitalia of men undergo changes, as well. There is a reduction in
sperm count related to the seminal vesicles having a thinner epithelium,
replacement of muscle tissue with connective tissue, and less capacity to
retain fluids. Structural changes in the seminiferous tubules include
increased fibrosis, thinning of the epithelium, thickening of the basement
membrane, and narrowing of the lumen.
There is atrophy of the testes and a reduction in the testicular mass.
Fluid ejaculated usually remains the same, although it contains lesser
amounts of living sperm. Testosterone decreases only slightly. More time is
required for an erection to be achieved, and it is more easily lost than in
younger men. Most older men experience an enlargement of the prostate
gland as some of the prostate tissue is replaced with a fibrotic tissue.
Although most prostatic enlargement is benign, there is an increased risk of
malignancy with age.
REPRODUCTIVE SYSTEM HEALTH

PROMOTION
An important way that nurses can promote reproductive system health is to
stress the value of regular examinations of this system. An annual
gynecologic examination is essential for the older woman; she should also
be knowledgeable about self-examination of the breasts. The National
Cancer Institute (2019) recommends that women over age 65 who have had
at least three normal Pap tests do not need to have a Pap test unless they are
infected with the human immunodeficiency virus (HIV), are
immunosuppressed, were exposed to diethylstilbestrol (DES) before birth,
or have been treated for a precancerous cervical lesion or cervical cancer.
Men with prostatic hypertrophy should be examined at least every 6 months
to ensure that a malignancy has not developed. Routine prostate-specific
antigen (PSA) testing in men with no history of prostate cancer is not
recommended. The nurse should also ensure that older men know how to
perform testicular self-examination. Finally, a complete history and
physical examination are essential to pinpoint specific areas that require
further investigation (Assessment Guide 20-1). Table 20-1 lists problems
associated with reproductive system conditions that the nurse may identify.
TABLE 20-1 Nursing Problems Associated With Reproductive
System Problems

REPRODUCTIVE SYSTEM HEALTH
INTERVIEW
Ask questions pertaining to the following:
Pain. “Do you experience pain in your lower abdomen or anywhere

else? Is there any tenderness, discomfort, itching, or pain anywhere
along your genital area? Do you experience pain with intercourse?”
Discharge. “Do you ever have secretions, blood, or other discharge
from your genitals?”
Sexual dysfunction. “Can you obtain an erection and hold it through
intercourse? What are your ejaculations like? Is your vagina sensitive
or overly dry during intercourse? Do you feel extra pressure or that
your partner’s penis is hitting a blockage during intercourse? Can you
have satisfying orgasms? Has there been any change in your sexual
pattern?”
Inspect the genitalia for lesions, sores, breaks, or masses. Note the
bleeding, discharges, odors, and other abnormalities.
If the female patient has not had a gynecologic examination or
mammogram within the past year, refer her accordingly.
For females, palpate the breasts for masses.
Review the procedure for self-examination of the breasts with female
patients, and provide instruction if the patient is unskilled in this
technique.

PSA testing is done routinely only when there is a history of prostate
cancer, not prostate discharge.
Chapter 31 discusses nursing considerations in fostering sexual function

and expression in older adults.
KEY CONCEPT
It is important to ensure that older women know how to perform breast
self-examination and that older men know how to perform testicular self-
examination.
SELECTED REPRODUCTIVE SYSTEM

CONDITIONS
Infections and Tumors of the Vulva
Age-related changes to the vulva cause it to be more fragile and more easily
susceptible to irritation and infection. Vulvar problems in the older woman
may reflect serious disease processes such as diabetes, hepatitis, leukemia,
and pernicious anemia. Senile vulvitis is the term used to describe vulvar
infection associated with hypertrophy or atrophy. Incontinence and poor
hygienic practices can also be underlying causes of vulvitis. Pruritus is the
primary symptom associated with vulvitis; blisters, redness, and swelling on
the labia and vulva also can occur. Patients who are confused and
noncommunicative may display restlessness and touch themselves at the
genitals; the nurse may discover that patients are suffering from irritation
and thickening of the vulvar tissue as a result of scratching. Initially,
treatment aims to find and manage any underlying cause. Good nutritional
status helps improve the condition, as does special attention to cleanliness.
Sitz baths and local applications of saline compresses or steroid creams may
be included in the treatment plan. Special attention is required to keep the
incontinent patient clean and dry as much as possible.
KEY CONCEPT
Age-related changes cause the vulva to be more fragile and more easily
susceptible to irritation and infection.
CONSIDER THIS CASE

Mr. and Mrs. C have been married for 50
years and, with their children all married, they live alone. They shared a
healthy sex life, but over the years, the frequency of intercourse and sexual
play has steadily declined. Recently, Mr. C has heard some of his friends
discussing their renewed sexual activity since taking drugs for their
erectile dysfunction. These conversations have caused Mr. C to desire sex
more frequently; however, his sexual advances have been rejected by his
wife who not only shows no interest but ridicules him for his. Their
differences in sexual desires are leading to many arguments between the
couple. During her visit for a routine gynecological examination, Mrs. C
tells you that her husband “has started to act like a sex maniac and is
making a fool of himself by not acting his age.”
THINK CRITICALLY
1. What are the possible factors causing each of the spouse’s
reactions?
2. How would you respond to Mrs. C?
Although pruritus commonly occurs with vulvitis, it may be a symptom

of a vulvar tumor. Pain and irritation may also be associated with this
problem. Any mass or lesion in this area should receive prompt attention
and be biopsied. The clitoris is commonly the site of a vulvar malignancy.
Most cases of vulvar cancer are diagnosed in women over age 70, with the
highest incidence and death rates associated with it being among white
women (U.S. Cancer Statistics Working Group, 2019). It may be manifested
by an unusual lump on the vulva that may itch and be painful or large,
painful, and foul-smelling fungating or ulcerating tumors. The adjacent
tissues may also be affected. A radical vulvectomy is usually the treatment
of choice and tends to be well tolerated by the older woman. Less
commonly used is radiation therapy, which is not tolerated as well as
surgery. Counseling regarding self-care practices, body image, and sexual
activity should be provided. Early treatment, before metastasis to inguinal
lymph nodes, improves prognosis.
Vaginitis
The postmenopausal woman experiences a variety of changes that affect the
vaginal canal, including reduction in collagen and adipose tissue, shortening
and narrowing of the vaginal canal, decreased elasticity, fewer vaginal
secretions, and a more alkaline vaginal pH as a result of lower estrogen
levels. The increased fragility of the fragile vagina in postmenopausal
women causes it to be more easily irritated, which heightens the risk of
vaginitis. Soreness, pruritus, burning, and a reddened vagina are symptoms,
and the accompanying foul-smelling vaginal discharge is clear, brown, or
white. As it progresses, vaginitis can cause bleeding and adhesions.
Local estrogens in suppository or cream form are usually effective in
treating senile vaginitis. Nurses should ensure that patients understand the
proper use of these topical medications and do not attempt to administer
them orally. Boric acid, zinc, lysine, or gentian violet douches may also be
prescribed. If the patient is to administer a douche at home, it is important
to emphasize the need to measure the solution’s temperature. Altered
receptors for hot and cold temperatures and reduced pain sensation
predispose the patient to burns from solutions excessively hot for fragile
vaginal tissue. Nurses should advise the older woman to avoid douches and
the use of perfumed soaps and sprays to the genitalia, wear cotton
underwear, keep the genital area clean and dry, and use lubricants (e.g., K-Y
jelly, vitamin E oil, and aloe vera gel) when engaging in intercourse. Good
hygienic practices help treat and prevent vaginitis.
Cancer of the Vagina
Approximately half of the cases of vaginal cancer occur in women over age
60. Risk factors include being infected with the human papillomavirus,
having had cervical cancer, a history of smoking, and having received
radiation therapy in the vaginal area; there also is an increased risk in
women whose mothers took DES during pregnancy with them. Treatment is
similar to that used for younger women and may consist of irradiation,
topical chemotherapeutic agents, or surgery, depending on the extent of the
carcinoma.
Problems of the Cervix

With age, the cervix becomes smaller, and the endocervical epithelium
atrophies. Occasionally, the endocervical glands can seal over, causing the
formation of nabothian cysts. As secretions associated with these cysts
accumulate, fever and a palpable tender mass may be evident. It is
important, therefore, for the older woman to receive regular gynecologic
examinations to check the patency of the cervix.
Cancer of the Cervix

The diagnosis of cervical cancer usually occurs between the ages of 40 and
49, with the highest rate for this disease being among Hispanic women,
followed by Black, White, Asian/Pacific Islander, and Native
American/Alaskan Native women (Centers for Disease Control and
Prevention, 2019). Although fewer than 20% of all diagnosed cases of
cervical cancer are in older women, the death rate is higher among this
group than in younger women. Despite the fact that most endocervical
polyps are benign in older women, they should be viewed with suspicion
until biopsy confirms such a diagnosis. Vaginal bleeding and leukorrhea are
signs of cervical cancer in aged women. Pain does not usually occur. As the
disease progresses, the patient can develop urinary retention or
incontinence, fecal incontinence, and uremia. Treatment of cervical cancer
can include radium or surgery. The American Cancer Society (2018)
suggests women over 65 years of age who have had regular screening in the
previous 10 years can stop cervical cancer screening as long as they haven’t
had any serious precancers (like CIN2 or CIN3) found in the last 20 years
(CIN stands for cervical intraepithelial neoplasia). Women with a history of
CIN2 or CIN3 should continue to have testing for at least 20 years after the
abnormality was found. Those who are high risk due to a suppressed
immune system should consult their health care provider, because more
frequent screening may be recommended.
Cancer of the Endometrium

Although not common, cancer of the endometrium primarily affects older
women. It is of higher incidence in women who have had a late onset of
menstrual periods, been infertile, have a personal or family history of
hereditary nonpolyposis colon cancer (HNPCC) or polycystic ovary
disease, used estrogen without progesterone, or who are obese. Any
postmenopausal bleeding should give rise immediately to suspicion of this
disease. Dilation and curettage are usually done to confirm the diagnosis
because not all cases can be detected by Pap smears alone. Treatment
consists of surgery, irradiation, or a combination of both. Early treatment
can prevent metastasis to the vagina and cervix. Endometrial polyps can
also cause bleeding and should receive serious attention because they could
be indicative of early cancer.
Cancer of the Ovaries

Ovarian cancer, which has a dramatic increase in incidence in women after
age 60, is responsible for only 2% of malignant disease in older women,
although it is the seventh leading cause of cancer deaths and the second
leading cause of deaths from gynecologic malignancies (American Cancer
Society, 2019; Siegel, Miller, & Jernal, 2020). Early symptoms are
nonspecific and can be confused with gastrointestinal discomfort, such as
abdominal pain, bloating, difficulty eating, and constipation. As this disease
progresses, the clinical manifestations include vaginal discharge, bleeding,
ascites, and the presence of multiple masses. Treatment may consist of
surgery, chemotherapy, hormone therapy, or radiation. Benign ovarian
tumors commonly occur in older women, and surgery is usually required to
determine whether tumors are malignant.
KEY CONCEPT
Although ovarian cancer is less common than endometrial or cervical
cancer, it is more deadly when it does occur.
Perineal Herniation
As a result of the stretching and tearing of muscles during childbirth and of
the muscle weakness associated with advanced age, perineal herniation is a
common problem among older women. Cystocele, rectocele, and prolapse
of the uterus are the types most likely to occur. Associated with this
problem are lower back pain, pelvic heaviness, and a pulling sensation.
Urinary and fecal incontinence, retention, and constipation may also occur.
Sometimes the woman is able to feel pressure or palpate a mass in her
vagina. These herniations can make intercourse difficult and uncomfortable.
Although rectoceles do not tend to worsen with age, the opposite is true for
cystoceles, which will cause increased problems with time. Surgical repair
is the treatment of choice and can be successful in relieving these problems.
Dyspareunia
Dyspareunia is a common problem among older women that accompanies
hormonal changes. Nulliparous women experience this problem more
frequently than women who have had children. Because vulvitis, vaginitis,
and other gynecologic problems can contribute to dyspareunia, a thorough
gynecologic examination is important, and any lesions or infections should
be corrected to alleviate the problem. All efforts should be made to help the
older woman achieve a satisfactory sexual life. (Chapter 31 presents a more
detailed discussion of problems affecting sexual intimacy.)
COMMUNICATION TIP
The fact that an older woman is single or widowed does not mean she
isn’t sexually active. Questions about sexual activity, enjoyment, and
satisfaction should be part of the comprehensive assessment. Offering
questions in a matter-of-fact manner can convey that there is nothing
unusual about being sexually active in late life and invite discussion.
(Such questions could include: “Are you sexually active? Are there
any problems with you engaging in sex or having a satisfying sexual
experience? Do you use any products to help with your vaginal
dryness, and if so, what?”) Such discussions can disclose other issues
that may need to be addressed, such as having unprotected sex with
multiple partners or using inappropriate products for vaginal
lubrication.
Cancer of the Breast

Decreased fat tissue and atrophy in older women’s breasts can cause
tumors, possibly present for many years, to become more evident. Because
breast cancer is the second leading cause of cancer deaths for women,
nurses should encourage women to have regular breast examinations.
Unfortunately, although the incidence of breast cancer increases with age,
the older the woman is, the less likely she is to perform self-examination of
breasts or receive yearly mammograms or breast examinations by a health
care professional. Diagnostic and treatment measures for women with
breast cancer are the same at any age. There are different opinions
regarding when mammograms should begin. The U.S. Preventive Services
Task Force (2016) recommends that women with average risk have annual
breast examinations starting at age 50, and the American Cancer Society
(2020) suggests mammograms annually for women 45 to 54 and every
other year or (if preferred by the woman) annually for women age 55 and
older, continuing as long as the woman is in good health and is expected to
live 10 years or more.
KEY CONCEPT
Although the incidence of breast cancer rises with age, older women are
the least likely group to receive mammograms and breast examinations
by a professional or to perform self-examinations of their breasts.

Erectile dysfunction , the inability to achieve and sustain an erection for
intercourse, is a problem affecting nearly half of the men over 70 years of
age. Although incidence rates increase with age, erectile dysfunction is not
a normal outcome of aging, but rather due to causes such as alcoholism,
drug abuse, diabetes, dyslipidemia, hypertension, hypogonadism, multiple
sclerosis, renal failure, spinal cord injury, thyroid conditions, and
psychological factors. Anticholinergics, antidepressants, antihypertensives,
digoxin, sedatives, and tranquilizers are among the medications commonly
used among older adults that can cause erectile dysfunction.
A variety of treatments can be used to address erectile dysfunction,
including oral erectile agents (e.g., sildenafil citrate [Viagra], vardenafil
HCl [Levitra], and tadalafil [Cialis]), drugs injected into the penis, penile
implants, vacuum pump devices, surgical implantation of devices, and
penile artery reconstruction. Some of the erectile drugs can have side effects
that may contraindicate their use for some individuals; therefore, careful
risk evaluation is essential before these types of drugs are prescribed.
COMMUNICATION TIP
If an older man offers that he has erectile dysfunction, it is important
to assess what he means by that. Older men do have a reduced ability
to raise an erection solely with a sexual thought, and they require
more direct physical stimulation to become erect. They also are more
likely to lose an erection if disturbed during intercourse by a noise or
other interruption. These experiences do not mean the man has erectile
dysfunction. If the man has the ability to become erect by
masturbating, he most likely does not have erectile dysfunction.
Asking specific questions to clarify symptoms can help the man avoid
seeking erectile dysfunction medications unnecessarily and facilitate
discussions of actions that can be taken to compensate for erectile
changes.
Benign Prostatic Hyperplasia

Most older men have some degree of benign prostatic hyperplasia , which
causes approximately one in four of them to have dysuria. Symptoms of this
problem progress slowly but continuously, as the enlarging prostate puts
pressure on the urethra; they begin with hesitancy, decreased force of
urinary stream, frequency, and nocturia as a result of obstruction of the
vesical neck and compression of the urethra that causes a compensatory
hypertrophy of the detrusor muscle and subsequent outlet obstruction.
Dribbling, poor control, overflow incontinence, and bleeding may occur. As
the hyperplasia progresses, the bladder wall loses its elasticity and becomes
thinner, leading to urinary retention and an increased risk of urinary
infection. Unfortunately, some men are reluctant or embarrassed to seek
prompt medical attention and may develop kidney damage by the time
symptoms are severe enough to motivate them to be evaluated.
Treatment can include prostatic massage, the use of urinary antiseptics,
and, if possible, the avoidance of diuretics, anticholinergics, and
antiarrhythmic agents. The most common prostatectomy approach used for
older men with prostatism is transurethral surgery. The patient should be
reassured that this surgery will not necessarily result in impotence. Realistic
explanations are needed, however, so the patient understands that this
surgery will not cause a sudden rejuvenation of sexual performance (Fig.
20-1). NURSING CARE PLAN 20-1 describes care for the older adult
recovering from prostate surgery.
FIGURE 20-1 Men benefit from realistic explanations of
the effects of treatments on sexual function.

THE OLDER ADULT RECOVERING FROM PROSTATE
SURGERY
Nursing Problem: Potential for infection and injury related to surgery
Nursing Problems: (1) Impaired sexual function related to surgery; (2)

Insufficient knowledge related to the effect of surgery on sexual function
Nursing Problem: Potential for urinary incontinence (stress or urge)
related to catheter removal
Cancer of the Prostate

Prostatic cancer increases in incidence with age, with the median age at
diagnosis being 66 years. The survival rates are excellent for this cancer,
although higher death rates are present among African American men, men
with advanced state cancer, and men between the ages of 75 and 84
(National Cancer Institute, 2020). Often, this disease can be asymptomatic;
however, most prostatic cancers can be detected by digital rectal
examination, which emphasizes the importance of regular physical
examinations. Benign hypertrophy should be followed closely because it is
thought to be associated with prostatic cancer, the symptoms of which can
be similar. Symptoms such as back pain, anemia, weakness, and weight loss
can develop as a result of metastasis. A PSA test assists with the diagnosis,
which is confirmed through biopsy.
If metastasis has not occurred, treatment may consist of monitoring,
irradiation, or a radical prostatectomy; the latter procedure will result in
impotency. Hormones may be used to prevent tumor dissemination.
Palliative treatment, used if the cancer has metastasized, includes
irradiation, transurethral surgery, chemotherapy, orchiectomy, and hormone
therapy. General principles associated with these therapeutic measures are
applicable to the older patient. Many men are able to continue sexual
performance after orchiectomy and during hormone therapy; the physician
should be consulted for specific advice concerning the expected outcomes
for individual patients.
Tumors of the Penis, Testes, and Scrotum

Cancer of the penis is rare and appears as a painless lesion or wartlike
growth on the prepuce or glans. The resemblance of this growth to a
chancre can cause a misdiagnosis or reluctance on the part of the patient to
seek treatment. A biopsy should be done for any penile lesion. Treatment
may consist of irradiation and local excision for small lesions and partial or
total penile amputation for extensive lesions.
Testicular tumors are uncommon in older people but are usually
malignant when they do occur; testicular enlargement and pain and
enlargement of the breasts are suspicious symptoms. Chemotherapy,
irradiation, and orchiectomy are among the treatment measures. As part of
the assessment, nurses should ascertain the patient’s knowledge of testicular
self-examination and provide education on this procedure if necessary; the
American Cancer Society can provide educational materials to use for this
instruction.
Scrotal masses, usually benign, can result from conditions such as
hydrocele, spermatocele, varicocele, and hernia. Symptoms and treatment
depend on the underlying cause and are the same as for younger men. As
with any reproductive system problem, counseling regarding self-care
practices, body image, and sexual activity is important.

Factors Associated With Adherence to Preventive
Cancer Screenings Among Middle-Aged African
American Women
Source: Guo, Y., Cheng, T. C., & Lee, H. Y. Social Work in Public Health ,
(2020):34 (7), 646–656.
The importance of breast cancer screening for women, which has been
strongly promoted by medical and health care professionals, is a common
practice among women. Despite this, African American women aged 45
years and older have a lower rate of breast cancer screening than any other
ethnicity. This longitudinal study sought to identify the factors that caused
African American women to obtain breast cancer screenings at a lower rate
than other women.
The study found that the women who were more likely to obtain breast
cancer screening were those who were older and/or had a higher education
level, a history of cancer, and a health care provider for female health.
Women whose calendars were too full to schedule health care visits, and
those who were distrustful of physicians or smoked regularly, were least
likely to seek breast cancer screening.
This study demonstrates that although information regarding the
importance of breast cancer screening is widely available and promoted,
nurses cannot assume women will seek this screening because there are
other factors that can influence their decision whether to do so. As part of a
general assessment, the nurse needs to ask the date of woman’s last
mammogram and, if one has not been obtained according to the
recommended frequency, the nurse should explore with the woman the
reason. Factors to review include whether the woman has full knowledge
about what the screening entails, the existence of a relationship with a
health care provider, insurance to cover the screening, misconceptions about
risks associated with the procedure, ability to locate a screening site with
hours compatible with one’s work schedule, and fears related to the
procedure or possible outcomes. The nurse should ask general questions to
reveal potential barriers, such as Can you tell me how you feel about getting
a mammography? Do you have any concerns or fears about this procedure?
Is there anything that has stopped you from getting breast cancer
screening?
Additional assessment for possible factors responsible for the lack of
breast cancer screening aids in guiding plans and actions to assist women in
obtaining this screening. Merely educating women about the importance of
breast cancer screening is insufficient; nurses also need to assist women in
overcoming the barriers to obtaining the screening.
PRACTICE REALITIES
Mr. and Mrs. Noonan, both 66 years old, have enjoyed healthy, satisfying
sexual activity throughout their 20 years of marriage. Mrs. Noonan had a
mastectomy for breast cancer 4 months ago and confides that, since she was
diagnosed, her husband has been more distant. Since the mastectomy, they
have not had intercourse, and he does not hug her anymore. Mrs. Noonan is
interested in resuming sexual activity, but her husband makes excuses and
appears uninterested.
What could be responsible for Mr. Noonan’s reaction? What could be
done to help the couple?

1. Discuss reasons for older adults not performing breast and testicular
self-examinations and measures nurses could take to promote older
adults performing these examinations.
2. Outline a program for ensuring regular breast and testicular
examinations are done for individuals living in an assisted living
community or nursing home.
3. Outline suggestions that could be offered to older women who state
that they find sexual intercourse uncomfortable due to the dryness of
their vaginal canal.
questions.
The nurse is providing a health awareness discussion on the reproductive

system at a local senior community center.
Nurse’s Notes
1300: Mrs. French, age 65, is attending the discussion and shares with
the nurse that she has a solid lump on her left inner breast and that her
left nipple is painful and has a dark brown discharge. She adds that her
nipples are retracted, and the surrounding nipple skin is thickened. She
further indicates that although she only sleeps 6 hours a night, her
appetite is good. She says to the nurse, “No one in my family has had
breast cancer, so I’m sure this isn’t serious.” The nurse suggests that she
should see her primary care provider (PCP) to discuss her signs and
symptoms.
Mr. Harding, age 72, is in the same meeting and asks the nurse, “Do you
think that I should make an appointment to go see my PCP?” The nurse
asks him if he would like to discuss his concerns privately. He responds,
“I don’t know what is wrong with me. I’m not as interested in sex as I
use to be, and when I am in the mood, I have a problem starting and
keeping an erection.” He adds, “For the past month, I have been having
urinary problems. I’m up frequently at night needing to urinate; my
stream is hard to start, but then stops and starts again when I think that I
am finished. My bladder never completely empties, causing me to
dribble urine throughout the day.” When the nurse asks if he has any
chronic health issues, he shares, “I have diabetes, hypertension, and high
cholesterol.” He then adds, “I never drink any alcohol nor abuse drugs,
and I stopped smoking 30 years ago. I work out every day, and I have
maintained an ideal weight.” The nurse agrees that Mr. Harding should
follow up with his PCP.
Chapter Summary
The health of the reproductive system has an impact on total body health.
Conditions of the reproductive system can be related to undiagnosed
disease processes that require attention, such as diabetes and infections.
Changes associated with aging contribute to infections of the vulva and
vagina. Cancers of the female reproductive tract occur less frequently with
age, except for ovarian cancer, which increases in incidence with age. The
incidence of breast cancer increases with age; because older women are the
least likely group to receive mammograms and breast examinations by a
professional or to perform self-examinations of their breasts, patient
education in this area is important.
Dyspareunia is a common problem in older women. Many older men
have erectile dysfunction. Nurses can benefit by guiding a sensitive
discussion of ways to manage these problems and promote satisfying sexual
activity.
The close relationship and trust that patients often have with nurses can
enable patients to more comfortably share concerns and symptoms related
to the reproductive system more openly with nurses than with other
members of the health care team. Nurses should include a review of the
reproductive system in their assessments of patients and assure abnormal
findings and symptoms are referred for evaluation and treatment.
Online Resources
Betty Allen Gynecologic Cancer Foundation
https://www.gyncancerfl.org
Cancer Treatment Centers of America: Prostate Treatment
https://www.cancercenter.com/cancer-types/prostate-cancer
Centers for Disease Control: Prostate Cancer
https://www.cdc.gov/cancer/prostate/basic_info/get-screened.htm
Gilda’s Club Worldwide
https://www.gildasclub.org
Malecare
https://www.malecare.com
National Cancer Institute: Mammograms
https://www.cancer.gov/types/breast/mammograms-fact-sheet
National Ovarian Cancer Coalition
http://www.ovarian.org/
References
American Cancer Society. (2018). The American Cancer Society guidelines for the prevention and
early detection of cervical cancer. Retrieved April 6, 2020 from
https://www.cancer.org/cancer/cervical-cancer/detection-diagnosis-staging/cervical-cancer-
screening-guidelines.html
American Cancer Society. (2019). Cancer facts and figures 2019 special section: Cancer in the
oldest old. Retrieved April 5, 2020 from https://www.cancer.org/content/dam/cancer-
org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2019/cancer-facts-and-
figures-special-section-cancer-in-the-oldest-old-2019.pdf
American Cancer Society. (2020). American Cancer Society screening recommendations for women
at average breast cancer risk. Retrieved August 5, 2020 from
https://www.cancer.org/cancer/breast-cancer/screening-tests-and-early-detection/american-
cancer-society-recommendations-for-the-early-detection-of-breast-cancer.html
Centers for Disease Control and Prevention. (2019). Rate of new cancers by race/ethnicity, female,
cervix. Retrieved April 5, 2020 from https://gis.cdc.gov/Cancer/USCS/DataViz.html
National Cancer Institute. (2019). HPV and pap testing. Retrieved August 5, 2020 from
https://www.cancer.gov/types/cervical/pap-hpv-testing-fact-sheet#when-should-a-woman-begin-
cervical-cancer-screening-and-how-often-should-she-be-screened
National Cancer Institute. (2020). Cancer Fact Sheet. Retrieved April 6, 2020 from
https://seer.cancer.gov/statfacts/html/prost.html
Siegel, R. L., Miller, K. D., & Jernal, A. (2020). Cancer statistics. CA: A Journal for Clinicians , 70
(1), 7–30.
U.S. Cancer Statistics Working Group. (2019). U.S. cancer statistics data visualizations tool. Age-
adjusted cancer incidence rates, vulva, female, United States. Retrieved April 5, 2020 from
https://gis.cdc.gov/Cancer/USCS/DataViz.html
U.S. Preventive Health Services Task Force. (2016). Breast cancer screening. Final recommendation
statement. Retrieved August 6, 2020 from
https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/breast-cancer-screening
CHAPTER 21
Mobility
Chapter Outline
Effects of Aging on Musculoskeletal Function
Musculoskeletal Health Promotion
Nutrition
Selected Musculoskeletal Conditions
Fractures
Osteoarthritis
Osteoporosis
Gout
General Nursing Considerations for Musculoskeletal Conditions
Managing Pain
Preventing Injury
LEARNING OBJECTIVES
1. Describe the effects of aging on musculoskeletal function.

2. List the benefits of activity.
3. Describe the adjustments that may need to be made in exercise
programs in late life.
4. Discuss the challenges older adults may face in maintaining an active
state.
5. List actions that could benefit an older adult who has impaired
mobility.
6. Discuss the role of nutrition in musculoskeletal health.
7. Describe factors contributing to, symptoms of, and related nursing care
for fractures, osteoarthritis, rheumatoid arthritis, osteoporosis, gout,
and podiatric conditions.
8. Discuss pain management measures for musculoskeletal problems.
9. Identify ways to reduce risks of injury associated with musculoskeletal
problems.
10. Describe measures to facilitate independence in persons with
musculoskeletal problems.
TERMS TO KNOW
Onychomycosisa fungal infection of the nail or nail bed
Osteoarthritisdegenerative joint disease in which there is progressive
deterioration and abrasion of joint cartilage, with the formation of new
bone at the joint surfaces
Osteoporosisbone condition characterized by low bone density and
porous bones
Sarcopeniaa decline in walking speed or grip strength associated with an
age-related decrease in muscle mass and/or function
Tinea pedisathlete’s foot; fungal infection of the foot
A variety of physical, psychological, and social benefits are gained through

regular activity. Physical activity aids respiratory, circulatory, digestive,
excretory, and musculoskeletal functions. Mental acuity and mood are
enhanced by the physiological effects of exercise. Physical activity can be a
means to engage in social activity; a physically fit state supports older
adults in participating in social events. Multiple health problems, such as
atherosclerosis, obesity, joint immobility, pneumonia, constipation, pressure
injuries, depression, and insomnia, can be avoided when an active state is
maintained. However, maintaining a physically active state is more
challenging in late life due to the effects of aging and the symptoms and
restrictions imposed by the chronic health conditions that are highly
prevalent among older adults. Gerontological nurses can contribute
significantly to the health of older adults by guiding them in maintaining
and improving their physical condition and by assisting them in effectively
managing conditions that could threaten an active physical state.
EFFECTS OF AGING ON
MUSCULOSKELETAL FUNCTION
The decline in the number and size of muscle fibers and subsequent
reduction in muscle mass decrease the body strength; grip strength
endurance declines. Connective tissue changes reduce the flexibility of
joints and muscles.
An increasing challenge associated with the decreased muscle mass
and/or function facing individuals as they age is sarcopenia —a decline in
walking speed or grip strength. It can be caused by disease, immobility,
decreased caloric intake, poor blood flow to muscle, mitochondrial
dysfunction, a decline in anabolic hormones, and an increase in
proinflammatory cytokines (Morley, Anker, & von Haehling, 2014; Norman
& Otten, 2018; Sun, Lee, Yim, Won, & Ko, 2017). When added to the
impaired capacity for muscle regeneration that occurs in late life, this can
lead to disability, particularly in patients with diseases or organ impairment.
In addition to the effects of aging and disease, activity can be impacted
by psychosocial factors. The loss of one’s spouse and/or friends can limit
the older adult’s participation in social and recreational activities, thereby
reducing opportunities for physical activity. Retirement is often
accompanied by reduced activity as one no longer has to prepare for, travel
to, and engage in work; social and recreational activities that could offer
opportunities for some exercise may be restricted due to financial
limitations or poor health. The relocation from the house in which the older
person raised his or her family to a smaller home, apartment, or retirement
community reduces housekeeping and maintenance functions that provided
some opportunity for movement.
Table 21-1 describes the effects of aging that challenge the older adult’s
ability to remain active.
TABLE 21-1 Aging and Risks to Maintaining an Active State
MUSCULOSKELETAL HEALTH
PROMOTION

Maintaining a physically active state is an increasingly difficult task not
only for older adults but also for many younger people. Fewer occupations
require hard physical labor, and those that do often use technological
innovations to perform the more strenuous tasks. Television viewing, social
media, and spectator sports are popular forms of recreation. Automobiles,
taxicabs, and buses provide transportation to destinations once conveniently
reached by walking. Elevators and escalators minimize stair climbing.
Modern appliances have considerably eased the physical energy expended
in household chores. Youths and adults are spending considerable amounts
of time sitting in front of computer screens, texting, playing video games,
and using virtual platforms for learning. Growing numbers of Americans
find that it is challenging to find the time for jogging or trips to the gym.
Educating and encouraging persons of all ages to exercise regularly is
an important way that gerontological nurses can influence the health of
today’s and future generations of older people. All exercise programs
should address:
Cardiovascular endurance. The ability of the heart, lungs, and blood

vessels to deliver oxygen to all body cells is enhanced by aerobic
training. Aerobic exercises include walking, jogging, cycling,
swimming, rowing, tennis, and aerobic dancing. For cardiac
endurance, these exercises must be performed long enough to require a
continuous supply of oxygen, which puts a demand on the
cardiopulmonary system to reach at least 55% of its maximum heart
rate (Box 21-1). Ideally, the heart rate should fall within the target
heart rate range during exercise. Depending on the exercise, moderate-
intensity aerobic activities should be done for at least 30 minutes, at
least 5 days a week (Centers for Disease Control, 2020a, 2020b).
Adjustments to desirable target heart rate range may need to be made
for persons with heart conditions or who are taking certain
medications; consultation with a primary care provider is important
before initiating an exercise program.
Flexibility. The ability to freely move muscles and joints through their
range of motion is another part of physical fitness. Gentle stretching
exercises help maintain flexibility of joints and muscles; stretching
exercises for about 5 to 10 minutes before and after other exercises can
reduce muscle soreness. Major muscle groups should be stretched at
least twice weekly.
Strength training. Strength and endurance are enhanced by exercises
that challenge muscles. Key elements of strength training are
resistance and progression. Resistance is achieved by lifting weights
and the use of weight machines; isometric exercises or the use of one’s
own body weight through calisthenics, such as push-ups and pull-ups,
are also good means of strength training. Progression involves
increasing the workload on the muscles, such as by lifting heavier
weights. The recommendation for most adults is to exercise a muscle
through a set of 8 to 12 repetitions at least twice weekly.
BOX 21-1 Calculating Maximum and Target

Heart Rates
Maximum heart rate = 220 − age
Target heart rate = maximum heart rate × 75%
Target heart rate range = 65% to 80% of maximum heart rate
(Commercial heart rate monitors, available at sports supplies stores,

can provide feedback on heart rate during exercise without the
inconvenience of having to stop to palpate the pulse.)
Essential to every health assessment is a review of the quality and

quantity of exercise. Nurses should address identified exercise deficits by
reviewing desirable exercise goals and strategies. Helping people to
develop good exercise habits today promotes a healthier older population in
the future.
POINT TO PONDER
Do you have regular exercise built into your life? If not, what factors
might help you accomplish this?

The enthusiasm for fitness is popular in our society; older adults are also
touched by this movement. Regular physical activity can delay or prevent
some of the age-related effects on cardiovascular function and improve
maximal oxygen uptake. It can lower resting systolic and diastolic blood
pressure. Physical activity can increase muscle strength and flexibility and
slow the rate of bone loss.
Exercise can improve body tone, circulation, appetite, digestion,
elimination, respiration, immunity, sleep, and self-concept. Participation in
exercise programs can also provide opportunities for socialization,
recreation, and motivational support (Fig. 21-1). Growing numbers of older
adults understand the benefits of and are engaging in exercise programs.
FIGURE 21-1 Planned activities can offer opportunities

for socialization as well as exercise.
Although exercise is highly beneficial to older adults, it can create

problems if adjustments are not made for their advanced age. In addition to
the effects of aging on musculoskeletal function described previously, age-
related changes affect a person’s ability to exercise. The reduced stroke
volume experienced with age is usually adequate during mild exercise,
although it is unable to increase in response to more strenuous exercise as
compared with younger hearts. This causes the heart rate to accelerate to
supply adequate circulation to the tissues. Not only does an increased
resistance to blood flow result in a higher systolic blood pressure during
rest but also systolic pressures can rise above 200 mm Hg during exercise.
Reduced vital capacity and increased residual capacity limit the air
movement, causing the respiratory muscles to work harder and the
respiratory rate to increase. The proportionate increase in body fat in older
bodies causes heat to dissipate less effectively, making older adults more
susceptible to heat stroke if they exercise in hot temperatures. The 10% to
15% decline in total body fluid that is experienced by late life means that
older adults can dehydrate more easily from perspiration during exercise.
These factors emphasize the importance of assessing older adults before
they start an exercise program and monitoring their status during physical
activity. Box 21-2 describes some of the guidelines that can assist older
adults to obtain maximum benefit from exercise programs.
BOX 21-2 Guidelines for Exercise Programs for

Older Adults
Ensure that a recent physical examination has been done to detect
conditions that could affect or be affected by an exercise program
(e.g., heart disease and diabetes). If health conditions are present,
consult with the physician as to restrictions or modifications to the
exercise program.
Assess the older adult’s current activity level, range of motion,
muscle strength and tone, and response to physical activity. In
collaboration with the patient, develop an exercise program that
recognizes interests, capacities, limitations, and realistic potential.
Emphasize exercises that focus on good speed and rhythm (e.g.,
low weights and high repetitions). Keep resistance exercises at a
low level and avoid isometric exercises.
Determine the training heart rate and evaluate heart rate during
exercise to ensure that the rate stays within a safe range.
To determine an age-adjusted training heart rate, subtract the
person’s age from 220 and multiply that answer by 70% (Centers
for Disease Control and Prevention, 2020a, 2020b; Page Reviewed
April 10, 2020). This calculates the maximum rate that will provide
vascular and other benefits without causing deleterious effects. The
resting heart rate can serve as the lower level and the training heart
rate as the upper level for a safe heart rate range during exercise.
Monitor pulse during exercise and reduce intensity and length of
exercise if heart rate is more than 10 beats above the target heart
rate.
Consult the primary care provider as to the appropriateness of the
exercise program for persons who have a resting heart rate
exceeding 100 beats per minute.
Advise the older adult to wear proper-fitting shock-absorbing shoes
with traction soles.
Encourage warm-up exercises (e.g., gentle stretching and flexing)
for at least 10 minutes before the person engages in the full exercise
program.
Provide for a period of cooling down after exercises.
Begin with a conservative exercise program and gradually increase
activity. Monitor vital signs and symptoms at various activity
levels. Note arrhythmias, significant changes in blood pressure,
dyspnea, shortness of breath, fatigue, angina, and intermittent
claudication.
Exercise programs are best followed if they match the individual’s

interests and needs. Some people dislike playing organized sports but enjoy
dancing, so helping them to find church or community groups that regularly
sponsor evenings of dancing may do more to promote exercise than
describing all the benefits of joining a tennis or bowling team. Likewise,
people who may not be able or willing to work out at a gym may be open to
lifting weights or using an exercise bike in their homes. A range of options
should be considered, such as brisk walking, swimming, yoga, and aerobic
exercises. In addition, people can take advantage of opportunities to
enhance physical activity during daily routines, such as climbing stairs
instead of taking an elevator, parking the car farther away from the
destination to increase walking, taking the dog on a longer route during
regular walks, and doing one’s own yard work and housecleaning (Fig. 21-
2).
FIGURE 21-2 Walking the dog outdoors can provide an
opportunity to incorporate physical activity into the older
adult’s daily routine.
COMMUNICATION TIP
When discussing exercise with older adults, better results may be
achieved if a plan is built on individual interests and needs rather than
a standardized exercise program. Instead of offering literature about
exercises or presenting recommendations to older adults, ask if they
have a history of exercising and what they think the likelihood of their
adhering to an exercise plan is. If they acknowledge that they don’t
like or adhere to exercise plans, review their interests and activities to
explore how these can be used to promote physical activity. Ask what
they feel will be useful to overcome barriers to exercise and physical
activity to promote self-engagement in the process. Engage older
adults in designing exercise plans, ask their reaction to the plans, and
aid them in exploring options to overcome obstacles. Plans that are
realistic and acceptable to older individuals are more likely to be
implemented and sustained than ideal exercise recommendations
prescribed by their providers that are inconsistent with individuals’
interests and preferences.
It is advisable to pace exercises throughout the day and avoid fatigue

from exercising because of potential muscle pain and cramping. Morning
stretching exercises loosen the stiff joints and muscles, which encourages
activity, whereas bedtime exercises promote relaxation and encourage sleep.
If an older person is not accustomed to a great deal of physical activity, he
or she should begin exercises gradually and increase them according to
individual progress. Some tachycardia normally may occur during the
exercises and continue for as long as several hours thereafter in older adults.
Longer periods must be allowed for the older person to perform exercises,
and rest periods should follow the activity. Warm water and warm
washcloths or towels wrapped around the joints may ease joint motion and
facilitate exercising.
The thinner, weaker, and more brittle bones of older people heighten the
risk of fractures. Exercises that stress an immobilized joint, strenuous
sports, and running and jumping exercises should be avoided to prevent
trauma. Older adults with cardiac or respiratory problems should seek
advice from their primary care provider about the amount and type of
exercise best suited for their unique capacities and limitations.
Increasing numbers of older adults are using exercises that were once
known to the complementary and alternative therapy arena. Tai Chi and
yoga are examples of such practices. These practices seem to have many
beneficial uses among older adults. Studies have demonstrated that in
addition to improving flexibility and balance, Tai Chi is beneficial in
promoting gait, quality of life, and positive mood in older adults (Kim,
Kim, & Lee, 2015; Taylor-Piliae & Finley, 2020). (See the Resources listing
at the end of this chapter for Web sites that provide more information about
yoga and Tai chi.)
Some older individuals may be unable to participate in formal exercise
programs. For these persons, it can be beneficial to build less aggressive
exercises into their daily activities and promote maximum activity during
routine care activities. For example:
Suggest that the patient do foot, leg, shoulder, and arm circling while
watching television. Scripting the alphabet letters using extremities
may be fun and cognitively stimulating at the same time.
Instruct the patient to do deep-breathing and limb exercises in the
period between awakening and rising from bed.
Encourage the patient to wash dishes or light laundry by hand to
exercise the fingers with the benefit of warm water.
When greeting a patient in the hall, ask the person to raise both arms as
high as possible and wave.
When giving a medication, ask the patient to bend each extremity
several times.
During bathing activities, ask the patient to flex and extend all body
parts.
KEY CONCEPT
People who are unable to participate in an aggressive exercise program
should stretch and exaggerate movements during routine activities to
promote range of motion, joint mobility, and circulation.
Figure 21-3 depicts several exercises that can easily be incorporated

into the older adult’s daily activities.
FIGURE 21-3 Exercises to do while in bed: A. Flexing
the knee with the opposite hand holding the foot for
assistance. B. Rolling from side to side. C. Scissor-like
crossing of the legs. D. Raising the chest. E. Flexing the
knees while lying on the abdomen. F. Bicycling. G.
Lifting a pillow over the head with the arms straight.
Exercises to do while sitting: H. Circling motion of the
shoulder joint with the arm at the side. I. Circling the
arms. J. Rotating the head. K. Flexing and extending the
neck. L. Pushing up in a chair with the use of the arms. M.
Kicking the legs while sitting. N. Rolling the foot on a
can. All exercises can be built into regular activities.
Exercises to do anytime: O. Rolling a pencil on a hard
surface. P. Flexing the fingers around a pencil. Q.
Exaggerating chewing motions. R. Rubbing the back with
a towel. S. Tightening the rectoperineal muscles. T.
Holding the stomach in to tighten the abdominal muscles.
At times, older adults may need partial or complete assistance with

exercises. The nurse or other caregivers will find it useful to remember the
following points:
Exercise all body joints through their normal range of motion at least
three times daily.
Support the joint and distal limb during the exercise.
Do not force the joint past the point of resistance.
Chapter 32 reviews the range-of-motion exercises and some of the

assistive devices that can help older adults to be active.

Cognitive and emotional states can influence physical activity. Depressed
individuals may be poorly motivated to engage in exercise or lack the
energy for physical activity. Persons living with dementia and other
cognitive impairments may lack the memory, judgment, or coordination to
safely exercise. However, inactive states lead to the ill effects of immobility
(e.g., poor circulation, fatigue, and reduced release of endorphins) that can
affect the brain. Promotion of physical activity, therefore, can have positive
effects on mood and cognition. Nurses can help patients with mood and/or
cognitive disorders in the development and implementation of an exercise
program appropriate for their capabilities and needs. Activities should be
planned according to the unique interests of the individual and could
include arts, crafts, travel, classes, gardening, auto repair, dancing, listening
to music, people watching, and collecting. Pets are frequently a source of
interest, activity, and companionship for older adults. Older adulthood can
also be a time for the development of new hobbies and interests.
Nurses are part of the interprofessional health care team that should
provide age-friendly care to older adults. The importance of mentation and
mobility assessments and acting on findings is embedded in the Age-
Friendly Health System’s Model of Care, an initiative of The John A.
Hartford Foundation and the Institute of Healthcare Improvement (IHI) in
partnership with the American Hospital Association and the Catholic Health
Association of the United States that began in 2017. The evidence-based set
of high-quality care, known as the 4Ms (see Fig. 21-4), addresses (1) What
Matters to the older adult, considering what is most important to the older
adult, family, and caregivers, goals and preferences; (2) Medication,
making sure all medications have a clear indication, prescribed at the lowest
effective dosage and frequency; (3) Mentation, assessing and managing
dementia, delirium, and/or depression; and (4) Mobility, maintaining or
improving mobility and function (Institute for Healthcare Improvement,
2019). Nurses’ assessment and management of mobility and mentation are
part of the 4Ms model of age-friendly care. Assessing mobility, for
example, can lead to key nursing interventions and actions to decrease risk
of falls, improve function, and improve overall safety of older adults in all
care settings.
FIGURE 21-4 Age-Friendly Health System’s Model of
Care. (Reprinted with permission from Institute of
Healthcare Improvement (IHI).)
KEY CONCEPT
Cognitive stimulation is as vital to an individual’s physical well-being as
physical activity. Likewise, physical activity can improve mood and
cognition.
Therapeutic recreation is structured leisure with a specific goal in mind,

for example, working with clay to exercise fingers, painting to express
feelings, and cooking classes to restore or maintain roles. Specialists in
recreation, music, art, or dance therapy can provide valuable assistance in
matching activities to the unique needs, interests, and capacities of older
adults.
With any activity, adequate time and patience are necessary. Slower
passage of impulses through the nervous system, sensory deficits, and the
vast storehouse of information being triggered and sorted in response to
psychological stimuli are just a few of the factors that interfere with rapid
reactions in older adults.
As listed in Box 21-3, the deconditioning effects of inactivity are significant
to older adults and exaggerate the age-related effects of sarcopenia. For a
person of any age, maintaining an active state can be challenging. For older
adults, age-related changes in muscle strength and endurance, reduced
opportunities for activity, and fatigue, pain, dizziness, dyspnea, and other
symptoms associated with health problems prevalent in later life can further
reduce activity levels.
BOX 21-3 Deleterious Effects of Inactivity

Changes in physiologic function
Reduced pulse rate
Increased cardiac workload
Decreased aerobic capacity
Decreased chest expansion and ventilation
Reduced muscle strength, tone, and endurance
Demineralization of bones, increased ease of fractures
Slower gastrointestinal motility
Slower metabolism and lymphatic circulation
Increased risk of complications
Hypostatic pneumonia
Pressure injuries
Poor appetite
Obesity
Constipation
Fecal impaction
Incontinence
Renal stone formation
Urinary tract infection
Joint stiffness, limited range of motion
Changes in mood and self-concept
Increased feelings of helplessness, depression
Perception of self as incapable, frail
Increased dependency
Reduced opportunities for socialization
KEY CONCEPT
Inactivity can result in deconditioning, which compounds the effects of
sarcopenia.
Because these real obstacles may hinder physical activity in later life,
special efforts are needed by older adults and those caring for them to
compensate for them. A crucial intervention is to educate the public,
especially caregivers, about the importance of physical activity for older
adults and its benefits such as lowering blood pressure, maintaining muscle
strength, preventing falls, aiding lymphatic circulation, sharpening mental
acuity, elevating mood, and improving digestion and elimination.
Sometimes families believe they are assisting their older relatives by “doing
for” and allowing them to be sedentary. Often, assisting with household
responsibilities not only stimulates functioning of the body’s systems but
also promotes a sense of worth by providing an opportunity for
productivity. Although physical activity may be more uncomfortable or
demanding than inactivity, future health problems and disability may be
spared by its regular practice.
Creativity in suggesting pastimes that can stimulate movement may be
a key to increasing opportunities for activity. For instance, encouraging
membership in a senior citizen’s club or senior center can motivate many
types of activities because the individual will have a reason to perform the
following tasks, among others:
Get out of bed

Prepare and eat breakfast
Bathe
Dress
Comb hair
Travel to the club
Negotiate a new environment
Interact with others
Participate in activities
Travel home
Undress
Those caring for older adults can enhance motivation by demonstrating

a sincere interest in their activities, for example, asking how they spent their
day, admiring crafts they made, or listening to the details of a trip.
Recognizing housekeeping efforts, using their handmade gifts, and
commenting on a well-groomed appearance are small but meaningful ways
to reinforce efforts to be active.
Nurses can inform older adults about local resources that can promote
activity, such as senior centers, exercise classes, educational and
recreational programs at local schools or colleges, volunteer opportunities,
and local clubs. In addition, they can promote activity by arranging
transportation for older adults to and from activities. For homebound older
people, special services offered by libraries, vision associations, Pets on
Wheels, social service organizations, faith communities, and other agencies
can provide resources and companionship that promote activity. Refer to the
Resources listing at the end of chapters for agencies that address specific
needs.
An older adult’s unique capacities and limitations, as well as interests,
will dictate the appropriate activities for that individual. Learning about an
older adult’s individual interests, preferences, and abilities can assist nurses
in identifying activities that will be familiar and enjoyable and help promote
person-centered care. Stereotyping older adults by assuming they all enjoy
exactly the same activities violates the underlying nursing principle of
individualized care and severely limits the opportunities available for older
adults. Older adults should be expected and encouraged to keep active and
interested in the world around them. They have an increased likelihood of
remaining capable, independent, functional, and physically and cognitively
stimulated.
Nursing Problem Highlight 21-1 describes additional interventions for
promoting mobility. Gerontological nurses can make a difference by
identifying those at high risk for developing musculoskeletal problems,
implementing interventions to prevent them, and implementing a
reconditioning program for those with chronic deconditioning.

REDUCED MOBILITY
Overview
Reduced mobility is a state in which movement is limited. Some degree of
mobility limitation is observed, ranging from the use of special equipment
for movement to total dependency on others for movement. Other signs
associated with this diagnosis could include decreased muscle strength or
control, restricted range of motion, impaired coordination, altered gait,
decreased level of consciousness, pain, paralysis, and imposed restrictions
on movement.
Arthritis, malnutrition, neuromuscular disease, sensory deficits, edema,
missing limb, cardiovascular disease, pulmonary disease, obesity, side
effects of medications, altered mood, and cognition.
Goals
The patient will increase mobility to optimal level. The patient will be free
from complications associated with impaired mobility.
Interventions
Assess muscle strength and tone, active and passive range of motion,
and mental status.
Review history for conditions that can limit mobility or require
alteration in the level of mobility. Consult with the physician as to
restrictions on mobility and any necessary modifications for
exercises.
Develop an individualized exercise program, which could include
passive or active range-of-motion exercises, structured exercise
classes, and walking programs (see Box 21-2).
Assist patient in maintaining good body alignment and frequent
position changes.
Promote good nutritional status. Consult with dietitians as needed.
If necessary, refer for canes, walkers, wheelchairs, braces, traction
devices, and other aids to increase mobility. Provide related health
teaching as needed.
Collaborate with physical therapist, occupational therapist,
recreational therapist, and other health team members to develop a
program to increase the patient’s mobility.
Encourage family and significant others to assist in efforts to increase
the patient’s mobility.
Provide diversional activities based on the patient’s interests and level
of function.
Observe for complications associated with immobility and seek
prompt correction. Instruct the patient in the recognition of
complications.
CONSIDER THIS CASE

Since retiring 6 years ago from his job as a
delivery man, 74-year-old Mr. E has become progressively more inactive.
His wife, who is of the same age and considerably more active, urges him
to exercise more, but Mr. E responds that he worked hard all his life and
now that he is retired he deserves to “kick back and take it easy.” Mr. E’s
increasingly stiff joints and reduced respiratory capacity cause him to have
difficulty walking more than a city block and climbing stairs. He
frequently nods off and has few interests other than television. His wife is
unhappy because they do not participate in activities together.
THINK CRITICALLY
1. What can be done to affect a change in Mr. E’s behavior?
2. How could you assist both Mr. and Mrs. E?
Nutrition
Good nutrition is an important factor in preventing and managing
musculoskeletal problems. A well-balanced diet rich in protein and
minerals will help maintain the structure of the bones and muscles. A
minimum of 1,500 mg calcium should be included in the diet daily for older
men and women who are not taking estrogen (1,000 mg for women taking
estrogen). Table 21-2 details good sources of calcium. If dietary intake of
calcium does not meet the daily requirement, supplements should be taken
to compensate for the deficient amount (i.e., if a person who should
consume 1,500 mg daily only derives an average of 1,000 mg from his or
her diet, a 500 mg supplement is appropriate).
TABLE 21-2 Good Sources of Calcium

In addition to quality of the diet, quantity is also an important
consideration. Obesity places strain on the joints, which aggravates
conditions such as arthritis. Weight reduction for those with obesity
frequently will decrease musculoskeletal discomfort and functional
limitations and should be promoted as a sound health practice for persons of
all ages.
SELECTED MUSCULOSKELETAL
CONDITIONS
Many older adults experience some degree of discomfort, disability, or
deformity from musculoskeletal disorders. In fact, musculoskeletal diseases
are the leading cause of functional impairment in older adults. Because
activity and mobility are vital to the overall health of older adults,
musculoskeletal problems that limit functional capacity can have
devastating effects (Table 21-3). Assessment for musculoskeletal problems
should consider not only the presence of these conditions but also the effect
they have on the older adult’s function (Assessment Guide 21-1).
Prevention of these problems and aggressive intervention to minimize their
impact if they are present should be integral parts of gerontological nursing
care.
TABLE 21-3 Nursing Problems Related to Musculoskeletal

Problems
MUSCULOSKELETAL FUNCTION
GENERAL OBSERVATION
Assessment of the musculoskeletal system can begin even before the
formal examination by noting the patient’s actions, such as transfer
activities, ambulation, and use of hands. Note observations regarding the
following:
Abnormal gait (Table 21-4)

Abnormality of structure
Dysfunction of a limb
Favoring of one side
Tremor
Paralysis
Weakness
Atrophy of a limb
Redness, swelling of a joint
Use of cane, walker, wheelchair
TABLE 21-4 Gait Disturbances
INTERVIEW
It is best to ask questions related to function, comfort, and range of motion
of the different parts of the body in order from head to toe. Examples of
questions include the following:
“Does your jaw ever get stiff or hurt when you chew?”
“Do you get a stiff neck?”
“Does your shoulder ever tighten?”
“Do your ribs ache or feel tender?”
“Do your hips hurt after you have walked for a while?”
“Are your joints stiff in the morning?”
“Do you have back pain or stiffness?”
“Do you have muscle cramps?”
“How far are you able to walk?”
“Are you able to take care of your home, get in and out of a bathtub,
and climb stairs?”
Also make specific inquiry into how the patient manages

musculoskeletal pain, particularly in reference to the use of over-the-
counter analgesics and any prescribed medications, heat, and topical
preparations.
Examine the active and passive range of motion of all joints. Note the
degree of movement with and without assistance. Specific areas to review
Shoulder. The patient should be able to lift both arms straight above
the head. With arms straight at the sides, the patient should be able to
lift them laterally above the head (i.e., 180 degrees) with hands
supine and 110 degrees with hands prone. The patient should be able
to extend the arms 30 degrees behind the body from the sides.
Neck. The patient should be able to turn the head laterally and to flex
and extend the head approximately 30 degrees in all directions.
Elbow. The patient should be able to open the arms fully and flex the
joint enough to allow the hand to touch the shoulder.
Wrist. The patient should be able to bend the wrist 80 degrees in the
palmar direction and 70 degrees in the dorsal direction. With a hand-
waving motion, the patient should be able to bend the wrist laterally
10 degrees toward the radial or thumb side and 60 degrees in the
direction of the ulnar side. The patient should be able to move the
hand to 90 degrees in the prone and supine positions.
Finger. The patient should be able to bend the distal joint of the
finger approximately 45 degrees and the proximal joint 90 degrees.
Hyperextension of 30 degrees should be possible.
Hip. While lying down, the patient should be able to abduct and
adduct the leg 45 degrees. With the patient lying on the back, the leg
should be able to be lifted 90 degrees with the knee straight and 125
degrees with the knee bent.
Knee. While lying on the stomach, the patient should be able to flex
the knee approximately 100 degrees.
Ankle. The patient should be able to point the toes 10 degrees toward
the head and 40 degrees toward the foot of the bed or examining
table. There should be a 35-degree inversion and a 25-degree
eversion.
Toe. The patient should be able to flex and hyperextend the toes
approximately 30 degrees. Note the patient’s active and passive range
of motion, as well as any weakness, tightness, spasm, tremor, or
contracture that may be evident.
Some muscle weakness can be anticipated, although the exact degree

will vary among individuals. The upper extremity usually shows greater
strength on the side of the dominant hand; there should be equal strength
in the lower extremities. To test the muscle strength in holding its shortest
position, have the patient hold the muscle in its shortest position and apply
force to cause the muscle to extend. Normally, a muscle will be able to
hold its shortest position under moderate resistance. Palpate all muscles
for tenderness, contractures, and masses.
Fractures
Trauma, cancer metastasis to the bone, osteoporosis , and other skeletal
diseases contribute to fractures in older adults. The neck of the femur is a
common site for fractures in older adults, especially in older women, and
most of these fractures result from falls. Colles’ fracture (break at the distal
radius) is one of the most frequent upper extremity fractures and often
occurs when attempting to stop a fall with an outstretched hand. Older
adults are also at risk for compression fractures of the vertebrae, resulting
from falls or lifting heavy objects. The more brittle bones of older adults
not only fracture more easily but also heal at a slower rate than in younger
adults, potentially predisposing older adults to the many complications
associated with immobility.
Knowing that the risk of fracture and its multiple complications is high
among older adults, the gerontological nurse must aim toward prevention,
drawing on the effectiveness of evidence-based practices. Because their
coordination and equilibrium are poorer, older people should be advised to
avoid risky activities (e.g., climbing on ladders or chairs to reach high
places). To prevent dizziness and falls resulting from postural hypotension,
older individuals should rise from a kneeling or sitting position slowly.
Safe, properly fitting shoes with a low, broad heel can prevent stumbling
and loss of balance, and hand rails for climbing stairs or rising from the
bath tub provide support and balance. Placing both feet near the edge of a
curb or bus before stepping up or down is safer than a poorly balanced
stretch of the legs (Fig. 21-5). Older adults should be careful where they are
walking to avoid tripping in holes and on damaged sidewalks or slipping on
slippery leaves or ice. Older eyes are more sensitive to glare, so sunglasses
may be helpful for improving vision outdoors. A nightlight is extremely
valuable in preventing falls during night visits to the bathroom. Other fall
prevention measures are discussed in Chapter 14.
FIGURE 21-5 A. The correct method for stepping to or
from a curb is to place both feet near the edge of the curb
before stepping up or down. B. The incorrect method is to
stretch the legs apart before stepping.
Because of the high prevalence and ease of fractures in older adults,

fracture should be suspected whenever older adults fall or otherwise subject
their bones to trauma. Symptoms include pain, change in the shape or
length of a limb, abnormal or restricted motion of a limb, edema, spasm of
surrounding tissue, discoloration of tissue, and bone protruding through the
tissue. The absence of these symptoms does not rule out the possibility of a
fracture. Overt signs and symptoms can be absent or appear a few days after
initial injury; in addition, the position of the fracture can prevent it from
being apparent on the initial roentgenogram. As the person is transported
for evaluation, immobility of the injured site and control of any bleeding are
essential.
KEY CONCEPT
The absence of typical signs of fracture does not guarantee that a bone is
not broken; therefore, close nursing observation is essential whenever a
bone has been subjected to trauma.
Fractures heal more slowly in older adults, and the risk of

complications is greater. Pneumonia, thrombus formation, pressure injuries,
renal calculi, fecal impaction, and contractures are among the complications
that special nursing attention can help prevent. Activity within the limits
determined by the physician should be promoted, including deep-breathing
and coughing exercises, isometric and range-of-motion exercises, and
frequent turning and position changes. Fluids should be encouraged and the
characteristics of urine output noted. Good nutrition will facilitate healing,
increase resistance to infection, and decrease the likelihood of other
complications. Joint exercise and proper positioning can prevent
contractures. Correct body alignment can be maintained with the use of foot
boards, trochanter rolls, and sandbags. Keeping the skin dry and clean,
preventing pressure, stimulating circulation through massage, and
frequently turning the patient may reduce the risk of pressure injuries.
Sheepskin, water beds, and alternating pressure mattresses are beneficial,
but they are not substitutes for good skin care and frequent position
changes.
The patient should be mobilized as early as possible. Because the
patient may fear using the fractured limb and avoid doing so, explanations
and reassurance are required to help the individual understand that the
healed limb is safe to use. Progress in small steps may be easier for the
patient to tolerate physically and psychologically; the first attempt at
ambulation may be to stand at the bedside, the next to walk to a nearby
chair, and the next to walk to the bathroom. Initially, it may be helpful for
two people to assist the patient with ambulation, especially because
weakness and dizziness are common. The principles of nursing
management for specific types of fractures are available in medical–surgical
nursing textbooks, and the nurse is advised to explore that literature for
more detailed information.
Osteoarthritis
Osteoarthritis is the progressive deterioration and abrasion of joint
cartilage, with the formation of new bone at the joint surfaces. This problem
occurs increasingly with advanced age and affects most persons over age 55
to some extent. It occurs in women more than in men and is the leading
cause of physical disability in older adults. Unlike rheumatoid arthritis,
osteoarthritis does not cause deformity and crippling—a fact that is
reassuring to the affected individual who fears the severe disability often
seen in persons with rheumatoid arthritis. For many years, it was believed
that the wear and tear of the joints as an individual ages were responsible
for the development of osteoarthritis; however, greater insights into the
pathophysiology of the condition have afforded a new understanding.
Disequilibrium between destructive (matrix metalloproteinase enzymes)
and synthetic (tissue inhibitors of matrix metalloproteinase) elements leads
to a lack of homeostasis necessary to maintain cartilage, causing the joint
changes. Excessive use of the joint, trauma, obesity, low vitamin D and C
levels, and genetic factors may also predispose an individual to this
problem. Patients with acromegaly have a high incidence of osteoarthritis.
Usually, osteoarthritis affects several joints rather than a single one. Weight-
bearing joints are most affected, the common sites being the knees, hips,
vertebrae, and fingers.
KEY CONCEPT
Osteoarthritis is the leading cause of physical disability in older people.
Systemic symptoms do not accompany osteoarthritis. Crepitation on

joint motion may be noted, and the distal joints may develop bony nodules
(i.e., Heberden’s nodes). The patient may notice that the joints are more
uncomfortable during damp weather and periods of extended use. Although
isometrics and mild exercises are beneficial, excessive exercise will cause
more pain and degeneration.
Analgesics may be prescribed to control pain. Acetaminophen is the
first drug of choice because of its safety over nonsteroidal anti-
inflammatory drugs. Because individual response to analgesics varies,
nurses should assess the effectiveness of various analgesics for the patient.
Rest, heat or ice, t’ai chi, aquatherapy, ultrasound, and gentle massage help
relieve joint aches. Acupuncture has been shown to bring about short-term
relief. Splints, braces, and canes provide support and rest to the joints. The
nurse should emphasize the importance of maintaining proper body
alignment and using good body mechanics when educating the patient. Cold
water fish and other foods high in the essential fatty acids have anti-
inflammatory effects and should be abundant in the diet. Vitamins A, B, B6,
C, and E and zinc, selenium, niacinamide, calcium, and magnesium are
among the nutritional supplements that could prove useful in controlling
symptoms. Weight reduction may improve the obese patient’s status and
should be encouraged. It is beneficial if a homemaker service or other
household assistance relieves the patient of strenuous activities that cause
the joints to bear weight. Occupational and physical therapists can be
consulted for assistive devices to promote independence and participation in
self-care activities. NURSING CARE PLAN 21-1 presents a sample care
plan for the patient with osteoarthritis.

THE OLDER ADULT WITH OSTEOARTHRITIS
Nursing Problem: Chronic pain related to joint inflammation, stiffness,
and fluid accumulation
Nursing Problem: Difficulty with physical mobility related to pain and
limited joint movement
Nursing Problem: Difficulty conducting activities of daily living such
as bathing, dressing, feeding, and toileting due to pain and/or joint
immobility
Nursing Problems: Actual or potential low self-esteem and/or body
image due to joint abnormality, change in mobility status, or change in
body appearance
If other treatments fail to improve the condition or the person suffers

severe functional limitation or pain, arthroplasty may be indicated.
Arthroplasty, or joint replacement, can be done to restore joint motion,
improve function, and reduce pain. At one time, older people were not
considered good candidates for arthroplasty, however, that thinking has
changed and increasing numbers of people over the age of 65 are having
joint replacements. Hip and knee joint replacements are those most
common, although arthroplasty can be performed on any joint. This
procedure is not advised for patients with neurotrophic joints or joint sepsis
or persons who are obese or have dementias or other conditions that would
interfere with their ability to cooperate with rehabilitation therapy.
Conditions such as peripheral vascular disease and diabetes mellitus
increase the risk of infection and interfere with wound healing. As moderate
to severe pain is often present postoperatively, analgesics are administered
around the clock. While assuring that pain is controlled adequately to
support early rehabilitation efforts, consideration must be given to the high
risk of adverse effects from analgesics that also can hamper rehabilitation; it
is important to closely observe patients’ reactions. Arthroplasty is
associated with a high risk of deep venous thrombosis and pulmonary
embolism for older patients; warfarin may be used prophylactically.
Patients and their caregivers need to be advised of precautions related to
anticoagulant therapy. Patients receive specific instructions pertaining to
their exercise, weight bearing, and activity restrictions. Nurses must see that
patients and their caregivers understand instructions and adhere to the plan
of care to ensure a successful outcome for the surgery. Planning
preoperatively for postoperative needs is beneficial.
Rheumatoid arthritis affects many persons, particularly those aged 20 to 40
years; it is a major cause of arthritic disability in later life as a result.
Fortunately, the incidence decreases after 65 years of age; most older
patients with this disease developed it earlier in life. Specifically, the
deformities and disability associated with this disease primarily begin
during early adulthood and peak during middle age; in old age, greater
systemic involvement occurs. This disease occurs more frequently in
women and in persons with a family history of the problem.
In rheumatoid arthritis, the synovium becomes hypertrophied and
edematous with projections of synovial tissue protruding into the joint
cavity. The affected joints are extremely painful, stiff, swollen, red, and
warm to the touch. Joint pain is present during rest and activity.
Subcutaneous nodules over bony prominences and bursae may be present,
as may deforming flexion contractures. Systemic symptoms include fatigue,
malaise, weakness, weight loss, wasting, fever, and anemia.
Encouraging patients to rest and providing support to the affected limbs
are helpful measures. Limb support should be such that pressure injuries
and contractures are prevented. Splints are commonly made for the patient
in an effort to prevent deformities. Range-of-motion exercises are vital to
maintain musculoskeletal function; the nurse may have to assist the patient
with active exercises. Physical and occupational therapists can provide
assistive devices to promote independence in self-care activities, and heat,
gentle massage, and analgesics can help control pain. Patients with
rheumatoid arthritis may be prescribed anti-inflammatory agents, disease-
modifying antirheumatic drugs (e.g., methotrexate), corticosteroids, and
immunosuppressive drugs. The nurse should be familiar with the many
toxic effects of these drugs and detect them early if they occur. If function
becomes significantly impaired or pain severe, joint replacement surgery
may be recommended.
Some patients with rheumatic heart disease are sensitive to the
“nightshade” foods: potatoes, peppers, eggplant, tomatoes, and other
solanines; eliminating these from the diet could prove beneficial. Herbs that
could improve symptoms include green tea and ginger for their anti-
inflammatory effects; however, limited research has been done to study the
benefits and risks of using these products.
Patients with rheumatoid arthritis and their families need considerable
education to be able to manage this condition. Patient education should
include information about the disease, treatments, administration of
medications, identification of side effects, exercise regimens, use of
assistive devices, methods to avoid and reduce pain, and an understanding
of the need for continued medical supervision. Accepting this chronic
disease is not an easy task for either the patient or the family. Finally, the
patient may be a prime target for salespeople offering a quick cure or relief
for arthritis and should be advised to consult a nurse or physician before
investing many dollars on useless fads.
Osteoporosis
Osteoporosis is the most prevalent metabolic disease of the bone; it
primarily affects adults in middle to later life, with some groups being at
higher risk than others (Box 21-4). Demineralization of the bone occurs,
evidenced by a decrease in the mass and density of the skeleton. Any health
problem associated with inadequate calcium intake, excessive calcium loss,
or poor calcium absorption can cause osteoporosis. Many of the following
potential causes are problems commonly found among older adults.
BOX 21-4 Risk Factors for Osteoporosis

Advanced age (women over 65 years, men over 80 years)
Ethnicity
White women with a northwestern European or British Isles
background
Asian women
Calcium deficiency
Vitamin D deficiency
Small-framed, thin women
History of early menopause
Estrogen deficiency
History of multiple pregnancies
Cigarette smoking
High alcohol consumption
Prolonged immobility
Decreased exercise
Diseases or chronic use of drugs that increase bone loss (e.g.,
corticosteroids, thyroid hormones, and anticonvulsants)
Family history of osteoporosis
Inactivity or immobility. A lack of muscle pull on the bone can lead to

a loss of minerals, especially calcium and phosphorus. This
particularly may be a problem for limbs in a cast.
Diseases. Cushing’s syndrome, an excessive production of
glucocorticosteroids by the adrenal gland, is believed to inhibit the
formation of bone matrix. The increased metabolic activity of
hyperthyroidism causes more rapid bone turnover, and the faster rate
of bone resorption to bone formation causes osteoporosis. Excessive
diverticulitis can interfere with the absorption of sufficient amounts of
calcium. Although the direct relationship is uncertain at this time,
diabetes mellitus can contribute to the development of osteoporosis.
The percentage of cases of osteoporosis that result secondary to other
diseases is relatively small.
Reduction in anabolic sex hormones. Decreased production or loss of
estrogens and androgens may be responsible for insufficient bone
calcium; therefore, postmenopausal women are at high risk.
Diet. An insufficient amount of calcium, vitamin D, vitamin C,
protein, and other nutrients in the diet can cause osteoporosis.
Excessive consumption of caffeine or alcohol decreases the body’s
absorption and retention of calcium.
Drugs. Heparin, furosemide, thyroid supplements, corticosteroids,
tetracycline, and magnesium- and aluminum-based antacids can lead to
osteoporosis.
POINT TO PONDER
To what risk factors for osteoporosis are you subject, and what can you
do to reduce them?
Osteoporosis may cause kyphosis and a reduction in height. The person

may experience spinal pain, especially in the lumbar region. The bones may
tend to fracture more easily. However, patients are often asymptomatic and
unaware of the problem until it is detected by radiography. Bone mass
density can be measured through several different types of noninvasive
techniques, including dual-energy x-ray absorptiometry (DEXA), which is
the most common method, peripheral dual-energy x-ray absorptiometry (P-
DEXA), and dual-photon absorptiometry (DPA).
Treatment depends on the underlying cause of the disease and may
include calcium supplements, vitamin D supplements, selective estrogen
receptor modulators (SERMs), and hormone therapy. A relatively recent
drug that has been shown beneficial in producing modest increases in bone
mass is a synthetic form of calcitonin, a hormone produced in the thyroid
that is a powerful inhibitor of osteoclastic activity (the cells that
continuously reabsorb bone). Bisphosphonates are another beneficial new
category of drugs that are primarily antiresorptive (i.e., they prevent or
significantly slow the normal osteoclastic activity responsible for the
resorption of bone). A diet rich in protein and calcium is encouraged.
Braces may be used to provide support and reduce spasms. A bed board is
also beneficial and should be recommended. Regular exercise can aid the
bones in retaining density.
The nurse must advise the patient to avoid heavy lifting, jumping, and
other activities that could result in a fracture. Persons providing care for
these patients must remember to be gentle when moving, exercising, or
lifting them because fractures can occur easily. Compression fractures of
the vertebrae are a potential complication of osteoporosis. Range-of-motion
exercises and ambulation are important to maintain function and prevent
greater damage. Physical therapists may be able to suggest appropriate
exercises to promote strength and function.
KEY CONCEPT
The bodies of persons with osteoporosis must be handled gently to avoid
fractures.
Gout
Gout is a metabolic disorder in which excess uric acid accumulates in the
blood. As a result, uric acid crystals are deposited in and around the joints,
causing severe pain and tenderness of the joint and warmth, redness, and
swelling of the surrounding tissue. During an acute attack, the pain can be
quite severe; the person may not be able to bear weight or have a blanket or
clothing rest on the affected joint. Attacks can last from weeks to months,
with long remissions between attacks possible.
Treatment aims to reduce sodium urate through a low-purine diet (e.g.,
avoidance of bacon, turkey, veal, liver, kidney, brain, anchovies, sardines,
herring, smelt, mackerel, salmon, and legumes) and the administration of
drugs. Alcohol should also be avoided because it increases uric acid
production and reduces uric acid excretion. Colchicine or phenylbutazone
can be used to manage acute attacks; long-term management could include
colchicine, allopurinol, probenecid, or indomethacin. Gout attacks can be
precipitated by the administration of thiazide diuretics, which raise the uric
acid level of the blood. Vitamin E, folic acid, and eicosapentaenoic acid can
be useful dietary supplements. Herbs such as yucca and devil’s claw reduce
symptoms in some persons. Nurses should monitor pain and encourage a
good fluid intake to prevent the formation of renal stones.
Foot problems that cause some degree of discomfort or dysfunction are so
common among older adults that this area has commanded a specialty of its
own: podogeriatrics. Lifelong foot problems, changes in gait, diseases that
affect the feet (e.g., gout, diabetes, and peripheral vascular disease), and
age-related loss of fat padding of the foot contribute to foot conditions.
The older person’s own shaving, cutting, and chemical treatment of
podiatric conditions can result in serious complications; therefore, patients
should be referred to podiatrists for the treatment of foot conditions. Nurses
should teach older adults about proper foot care (e.g., keeping feet clean
and dry, wearing safe and proper-fitting shoes, exercising feet, and cutting
nails straight across and even with the top of the toe) and the importance of
seeking professional podiatric care for problems. Nurses can offer foot
massages because they can aid in stimulating circulation, reducing edema,
and promoting comfort. (Foot massages may be contraindicated in patients
with peripheral vascular disease or lesions, so it is important to consult with
the physician first.)
Because of the impact of podiatric problems on mobility and
independence, these conditions need to be effectively identified and treated.
Some of the common conditions are discussed below.
Calluses
Calluses (plantar keratoses) are caused by friction and irritation on the feet
that create layers of thickened skin. Reduced fat padding of the foot,
dryness of the skin, decreased toe function, and poor fitting shoes contribute
to callus formation. They usually appear on the heels and soles and,
although not painful, can be unsightly. There is the risk that people will
attempt to shave or cut off calluses from their feet and risk injuring their
skin. Massaging the feet with lotions and oils can aid in preventing calluses.
Corns
Corns are cone-shaped layers of thick, dry skin that form over a bony
prominence. Pressure on the area causes discomfort as the tip of the cone
presses into the tissue. Additional pressure increases the size of the corn
and, consequently, the pain. U-shaped corn pads and loosely wrapping the
toe in lamb’s wool are superior to oval or round corn pads, which can
restrict circulation. As with calluses, patients should be advised not to
attempt to remove corns on their own.
Bunions (Hallux Valgus)

A bunion or bursa is a bony prominence over the first metatarsal head (Fig.
21-6A). There is a medial deviation of the first metatarsal with abduction of
the great toe in relation to that metatarsal. Bunions occur more often in
women—not surprising considering women’s shoe styles that commonly
have tight toe fit and the tight hosiery that pull toes together. Some bunions
are hereditary in nature. The increased width of the foot caused by the
bunion can cause difficulty in finding properly fitting shoes. Shoe repair
shops can stretch shoes to accommodate bunions; custom-made shoes are
also beneficial. Surgery may be indicated for some cases.
FIGURE 21-6 Foot disorders can cause pain and
dysfunction. A. Bunion. B. Hammer toe.
Hammer Toe (Digiti Flexus)

Hammer toe is a hyperextension at the metatarsophalangeal joint with
flexion and often corn formation at the proximal interphalangeal joint. The
toe begins to resemble the shape of the hammers inside a piano, thus its
name (Fig. 21-6B). Although the joint itself is not painful, pressure to the
area results in discomfort. Orthotics can provide symptomatic relief, but
surgery is necessary for correction.
Plantar Fasciitis
A common cause of heel pain, often mistaken for a spur, is plantar fasciitis.
The plantar fascia is a thick ligamentous band in the bottom of the foot that
runs from the ball of the foot to the heel, where it is attached. Poor
alignment of the foot that causes pronation or supination of the foot during
walking results in stretching and stress of the plantar fascia. Plantar fasciitis
is an inflammation of this band at its heel attachment. Pain is the primary
symptom and occurs in the center or the inner side of the heel. Pain is worse
after a period of rest; most people experience the most pain in the morning.
After walking, the pain may subside but tends to increase as pressure is put
on the heel from walking or standing. Pain can radiate to the ankle or arch
of the foot if nerves become irritated secondary to the swollen plantar
fascia.
Symptomatic treatment can include stretch exercising of the foot
(pulling up on the ball of the foot), applying ice to the heel for 30-minute
periods, and wearing cushions in the heel and shoes with heels elevated
about 2 in. The most effective means of relieving pain and preventing
inflammation is to have the foot realigned through the use of custom-made
orthotics. Patients need to be advised that they may not note improvement
until several months after beginning treatment.
Infections
Housing of the foot in shoes, particularly the ones made from synthetic
materials, creates a warm, moist environment that facilitates fungus and
bacterial growth. Onychomycosis is a fungal infection of the nail or nail
bed in which the toenail appears enlarged, thick, brittle, and flaky. As the
fungus forms under the nail and displaces it up, the sides of the nail are
pushed into the skin and cause pain. Antifungal preparations assist in
eliminating the infection, but these infections are challenging to treat.
Tinea pedis , better known as athlete’s foot, is a fungal infection of the
foot that can cause burning and itching; the skin surface will peel, crack,
and be red, often with vesicle eruptions. The breaks in the skin surface
provide easy entry for bacteria.
Ingrown Nails (Onychocryptosis)

Ingrown nails can occur due to tight-fitting shoes or cutting the nail
excessively short. As the nail grows, its edge cuts into the tissue, leading to
inflammation. Soaks and topical antibiotics may be prescribed; usually, a
podiatrist can correct this problem by removing the ingrown portion and
cleaning the area.
GENERAL NURSING
CONSIDERATIONS FOR
MUSCULOSKELETAL CONDITIONS
Managing Pain
Pain often accompanies musculoskeletal problems. Degenerative changes in
the tendons and arthritis are often responsible for painful shoulders, elbows,
hands, hips, knees, and spines. Cramps, especially during the night, are
common in calves, feet, hands, hips, and thighs. Joint strain and damp
weather more frequently cause musculoskeletal pain in the old than in the
young.
Pain relief is essential in promoting optimal physical, cognitive, and
social function. Unrelieved pain can interfere with older adults’ abilities to
engage in self-care, manage their households, and maintain social contact.
To enrich the quality of life, every effort should be made to minimize or
eliminate pain. Often, heat relieves muscle spasms; a warm bath at bedtime
and keeping the extremities warm with blankets and clothing can reduce
spasms and cramps throughout the night and promote uninterrupted sleep.
Because older adults are at high risk for burns, care must be taken to avoid
injury if heat applications or soaks are used especially for those with
peripheral neuropathy that may decrease sensitivity and awareness to heat.
Passive stretching of the extremity can be helpful in controlling muscle
cramps. Excessive exercise and musculoskeletal stress should be avoided,
as well as situations known to cause pain, such as heavy lifting or damp
weather. Back rubs using slow, long, rhythmic strokes can promote
relaxation and comfort. Pain in the weight-bearing joints can be alleviated
by resting those joints, supporting painful joints during transfers, and using
a walker or cane (Fig. 21-7). Correct positioning, whereby all body parts
are in proper alignment, can help prevent and manage pain. Accidental
bumping against the patient’s bed or chair and rough handling of the patient
during care activities must be prevented. Nurses may also need to
emphasize to other caregivers the need for extra gentleness in turning and
lifting older patients.
FIGURE 21-7 Methods for reducing musculoskeletal
pain. A. Good body alignment. B. Support of parts of the
limb adjacent to the painful joint when moving or lifting.
C. Use of a walker or cane.
KEY CONCEPT
Unrelieved pain can significantly affect an older adult’s independence
and quality of life.
Diversional activities are useful in preventing the patient’s

preoccupation with pain. Acupuncture, acupressure, and chiropractic
therapy are among the alternative therapies that may help some patients
control pain. Guided imagery and therapeutic touch may also prove helpful.
The goal is to aid the patient in achieving the maximum level of activity
with the least degree of pain.
Preventing Injury
Safety considerations are essential for all older adults because of their high
incidence of accidents and musculoskeletal injuries and the prolonged time
required for healing. Prevention includes paying attention to the area where
one is walking; climbing stairs and curbs slowly; using both feet for support
as much as possible; using railings and canes for added balance; wearing
properly fitting, safe shoes for good support; and avoiding long trousers,
nightgowns, or robes. The importance of the safe use of heat has already
been mentioned; it is useful for patients to learn how to measure water
temperature and use hot-water bottles and heating pads safely. Patients with
peripheral vascular disease must be warned that the local application of heat
can cause circulatory demands that their body will be unable to meet; other
means of pain relief may be more beneficial to them. Warm baths can
reduce muscle spasm and provide pain relief, but they can also cause
hypotensive episodes leading to dizziness, fainting, and serious injury.
Carelessly turning patients so that legs hit the bed rail, dropping them
even a short distance into a chair during a transfer, restraining them in an
unaligned position, roughly handling a limb, or attempting to use force to
straighten a contracture can lead to muscle strain and fractures. Gentle
handling will prevent unnecessary musculoskeletal discomfort and injury.
Any loss of independence associated with the limitations imposed by
musculoskeletal problems has a serious impact on physical, emotional, and
social well-being. Therefore, nurses must explore all avenues to help
patients minimize limitations and strengthen capacities, thereby promoting
the highest possible level of independence. Canes, walkers, and other
assistive devices can often provide significant aid in compensating for
handicaps and should be used when feasible (Fig. 21-8). Physical and
occupational therapists can be valuable resources in determining
appropriate assistive devices for use with specific deficits. Chapter 32
discusses the mobility aids in more detail.
FIGURE 21-8 Self-care devices can help the client with
musculoskeletal problems to achieve the maximum
independence possible. A. Assistive feeding devices help
the client to grasp and get food on the utensils. B. A
reacher is a handy device for the client with mobility
restrictions. C. A raised toilet seat makes it easier for
people who have trouble lowering themselves to the toilet
seat to safely use the toilet at home.

Proto Tai Chi: In Search of a Promising Group
Exercise for the Frail Elderly
Source: Taylor-Piliae, R. E., & Finley, B. A. (Published online June 9,
2020). European Journal of Cardiovascular Nursing. doi:
10.1177/1474515120926068.
Taylor-Piliae and Finley (2020) conducted a meta-analysis analyzing 15
clinical trials that included a tai chi intervention in adults with
cardiovascular disease. Thirteen of the clinical trials were randomized
controlled studies, and two were quasi-experimental students with
comparison groups. Eight of the studies (53.3%) were conducted in Asia,
five (33.3%) in North America, and two (13.3%) in Europe. There were a
total of 1853 participants (mean age 66 years) across all studies. Two
studies included participants with coronary heart disease (n = 164, mean
age 65 years, 37% female); five studies included participants with heart
failure (n = 530, mean age 68 years, 34% female); four studies included
participants with hypertension (n = 930, mean age 62 years, 55% female);
and four studies included participants post-stroke (n = 229, mean age 67
years, 51% female).
The Tai Chi intervention, mostly Yang style (60%), ranged from 6
weeks to 1 year, with a mean length of 17 weeks. On average, 36 sessions
were provided, with an average intervention adherence rate of 83%. The
control conditions included usual care (8 studies), non-Tai Chi exercise (6
studies), or education (1 study). Collectively, the average control condition
adherence rate was 85%. Outcome measures included quality of life (14
studies), psychological distress (2 studies), stress (1 study), anxiety (2
studies), and depression (7 studies), using multiple assessment
questionnaires or measurement tools.
This meta-analysis study showed that tai chi interventions among adults
60 years of age and older with cardiovascular disease led to significantly
improved overall quality of life, mental health quality of life, physical
health quality of life, less depression, and less psychological distress
compared to the control group receiving usual care or other type of exercise
or educational intervention. Participants with coronary heart disease who
received the Tai Chi intervention demonstrated better mental health quality
of life compared to controls. Participants with heart failure who received
the Tai Chi intervention demonstrated significantly less depression and
psychological distress but no significant improvement in quality of life
compared to controls. Participants with hypertension who received the Tai
Chi intervention demonstrated improved physical health quality of life
compared to controls. Participants post-stroke receiving the Tai Chi
intervention showed a nonsignificant, moderate effect for less depression
compared to controls. Overall, this study demonstrates that Tai Chi, a
nonpharmacological approach to promote psychological well-being in older
adults with cardiovascular disease, has additional benefits to overall health
and well-being other than solely physical benefits.
PRACTICE REALITIES
While working on a hospital unit, you notice that older patients are allowed
to spend most of their time in bed, and when out of bed, they are pushed in
a wheelchair. Nearly all of these patients were ambulatory prior to
admission. You observe that many of these patients are too weak to safely
ambulate at discharge.
At a team meeting you raise the issue and suggest plans be developed to
reduce unnecessary immobility in older patients and assist them with
ambulation at intervals throughout the day. Several of the other nurses
object, stating that this will increase the risk of falls on the unit. They add
that this also will require more nursing time and they are working at bare-
bones staffing.
You want to have harmony with your team but believe their views are
not in the patients’ best interest.
What are your options?

1. What obstacles do older adults face when trying to maintain an active
state? What aspects of society at large discourage physical activity in
older adults?
2. Outline the contents of an exercise education program for a group of
healthy older adults living in the community.
3. List special problems the following older adults may experience in
achieving adequate exercise: a resident of a long-term care facility
who has dementia, a depressed widow who lives alone in the
community, and a man who must seek reemployment after retiring.
4. Describe how a nurse’s attitude toward older adults can affect his or
her participation in activities that promote movement.
5. What situations could an older adult encounter during an acute
hospitalization that could increase the risk of sustaining a fracture?

questions.
The home health nurse is making an initial visit to Mr. Radford, who is
retired and lives with his wife.Nurse’s Notes
1400: Since retiring 6 years ago from his job as a construction foreman,
the 74-year-old has become progressively more inactive, in part as a
result of several medical diagnoses. The client demonstrates moderate
difficulty getting out of his chair and walking to the table where his wife
is sitting. His wife, who is of the same age and considerably more active,
urges him to exercise more, but Mr. Radford responds that he worked
hard all his life and now that he is retired, he deserves to “sit in my chair
and take it easy if I want to.” His wife is unhappy because they do not
participate in activities together. She states, “Ed frequently falls asleep in
his chair while doing what he does most of the time—watching
television.” Mr. Radford acknowledges that he “has difficulty walking
more than from here to the corner, and steps make me winded.”
Chapter Summary
With age, the musculoskeletal system experiences a reduction in muscle
mass and strength, grip endurance, and joint flexibility. Although this can
be a challenge for many older adults, maintaining av physically active state
is important, and individualized exercise programs should be promoted that
address cardiovascular endurance, flexibility, and strength training. Because
cognitive and emotional states can influence physical activity, as well as be
influenced by it, nurses should aid older adults in developing exercise
programs that are tailored for their capabilities, needs, and interests. Nurses
and interprofessional team members should help older adults maintain or
improve mobility and overall function.
Osteoporosis and other diseases that are more prevalent in later years
contribute to a high risk for fractures. Identifying risks and instructing
patients in safety measures that can prevent falls can aid in reducing this
risk. The ease at which older bones fracture and the possibility that a
fracture could be present without symptoms initially being present support
the importance of suspecting a fracture whenever older adults fall or subject
their bones to trauma until evaluation rules this out. The immobility that
could result following a fracture subjects older patients to pneumonia,
thrombus formation, pressure injuries, renal calculi, fecal impaction,
contractures, and other complications. Early mobilization and close
monitoring are essential.
Osteoarthritis is one of the leading causes of disability in older adults.
Analgesics are commonly used to control pain and require ongoing
assessment for effectiveness. Heat, ice, t’ai chi, aquatherapy, acupuncture,
and massage are among the other measures that could benefit some patients.
If other treatments fail to improve the condition or the person suffers severe
functional limitation or pain, arthroplasty may be indicated.
Although it primarily affects people aged 20 to 40 years of age,
rheumatoid arthritis is a major cause of arthritic disability in the older adult
population. Treatment includes limb support, range-of-motion exercises,
and medications. Close monitoring for the toxic effects of medications is
essential.
Immobility, reduction in anabolic sex hormones, low calcium intake,
and certain medications and diseases contribute to the demineralization of
the bones known as osteoporosis. DEXA, which is the most common
method, P-DEXA, and DPA are some of the techniques used to measure
bone density. Treatment depends on the underlying cause.
Gout, a metabolic disorder in which excess uric acid accumulates in the
blood, causes uric acid crystals to be deposited in and around the joints,
causing severe pain and tenderness of the joint and warmth, redness, and
swelling of the surrounding tissue. During an acute attack, pain and
sensitivity of the joint is severe. Medications, avoidance of alcohol, and a
low-purine diet are among the treatment measures.
Podiatric conditions are common among older adults. It is important
that patients be advised not to attempt to manage these conditions on their
own but to seek the care of a podiatrist.
Nursing measures to assist patients with their musculoskeletal
conditions include pain management, injury prevention, and the promotion
of independence. Occupational and physical therapists can assist in
developing individualized plans to assist with the management of these
conditions and to promote maximum mobility.
Online Resources
Arthritis Foundation
http://www.arthritis.org
HealthinAging.org
Arthritis: https://www.healthinaging.org/a-z-topic/arthritis
Joint Problems: https://www.healthinaging.org/a-z-topic/joint-problems
Physical Activity: https://www.healthinaging.org/a-z-topic/physical-activity
International Association of Yoga Therapists
http://www.iayt.org
National Institute of Arthritis and Musculoskeletal and Skin Diseases
(NIAMS)
http://www.niams.nih.gov
National Osteoporosis Foundation
http://www.nof.org
Tai Chi for Health Institute
https://taichiforhealthinstitute.org
Tai Chi Tao Center
http://www.taichitaocenter.com
References
Centers for Disease Control and Prevention. (2020a). How much physical activity do older adults
need? Retrieved June 19, 2020 from
https://www.cdc.gov/physicalactivity/basics/older_adults/index.htm
Centers for Disease Control and Prevention. (2020b). Target heart rate and estimated maximum heart
rate. Retrieved June 6, 2020 from
http://www.cdc.gov/physicalactivity/everyone/measuring/heartrate.html
Institute for Healthcare Improvement. (2019). Age-friendly health systems: Guide to using the 4Ms in
the care of older adults. Boston, MA: Institute for Healthcare Improvement.
Kim, H., Kim, Y. L., & Lee, S. M. (2015). Effects of therapeutic Tai Chi on balance, gait, and quality
of life in chronic stroke patients. International Journal of Rehabilitation Research , 38 (2), 156–
161. doi: 10.1097/MRR.0000000000000103.
Liu-Ambrose, T., Davis, J. C., Best, J. R., Dian, L., Madden, K., Cook, W., … Khan, K. M. (2019).
Effect of a home-based exercise program on subsequent falls among community-dwelling high-
risk older adults after a fall: A randomized clinical trial. Journal of the American Medical
Association , 321 (21), 2092–2100. doi: 10.1001/jama.2019.5795.
Morley, J. E., Anker, S. D., & von Haehling, S. (2014). Prevalence, incidence, and clinical impact of
sarcopenia: Facts, numbers, and epidemiology. Journal of Cachexia, Sarcopenia, and Muscle , 5
(4), 253–259.
Norman, K., & Otten, L. (2018). Financial impact of sarcopenia or low muscle mass: A short review.
Clinical Nutrition , 38 (4), 1489–1495. doi: 10.1016/j.clnu.2018.09.026.
Sun, D. S., Lee, H., Yim, H. W., Won, H. S., & Ko, Y. H. (2017). The impact of sarcopenia on health-
related quality of life in elderly people: Korean National Health and Nutrition Examination
Survey. Korean Journal of Internal Medicine , 34 (4), 877–884. doi: 10.3904/kjim.2017.182.
Taylor-Piliae, R. E., & Finley, B. A. (Epublished online ahead of print June 9, 2020). Tai Chi exercise
for psychological well-being among adults with cardiovascular disease: A systematic review
and meta-analysis. European Journal of Cardiovascular Nursing. doi:
10.1177/1474515120926068.
CHAPTER 22
Neurologic Function
Chapter Outline
Effects of Aging on the Nervous System
Neurologic Health Promotion
Selected Neurologic Conditions
General Nursing Considerations for Neurologic Conditions
Preventing Injury
LEARNING OBJECTIVES
1. Describe the effects of aging on the nervous system.

2. List risk factors for neurologic problems in older adults.
3. Describe measures to promote neurologic health in older adults.
4. Identify signs and symptoms of neurologic disorders in older adults.
5. Describe the symptoms, unique features, and related nursing care for
Parkinson’s disease, transient ischemic attacks, and cerebrovascular
accidents in older adults.
6. Discuss actions that promote independence in older persons with
neurologic problems.
7. Describe measures to reduce the risk of injury in older persons with
neurologic problems.
TERMS TO KNOW
Bradykinesiaslow movement
Cerebrovascular accidentstroke; interruption in blood supply to the
brain
Dysarthriadifficulty forming words associated with poor muscular
control due to damage to the central or peripheral nervous system
Dysphasiadifficulty expressing or comprehending verbal or written
language due to brain lesion or injury
Hemiparesisweakness on one side of the body
Hemiplegiaparalysis on one side of the body
Hemianopsiadecreased vision or blindness in half of one eye or the same
half of both eyes
Parkinson’s diseaseprogressive degeneration of neurons in the basal
ganglia resulting in the reduced production of dopamine
Transient ischemic attack (TIA)temporary or intermittent neurological
event that can result from any situation that reduces cerebral circulation
The nervous system has a profound influence on our interaction with the
world. A healthy system enables us to sense the pleasures around us, protect
ourselves from harm, solve problems, derive intellectual stimulation,
interact socially, and communicate our needs, thoughts, and desires. Every
aspect of our basic activities of daily living depends on a good neurologic
status. Dysfunction of this system has a ripple effect on other systems and
can profoundly affect health, safety, normalcy, and general well-being.
EFFECTS OF AGING ON THE

NERVOUS SYSTEM
With age, loss of nerve cell mass causes some atrophy of the brain and
spinal cord, and brain weight decreases. The number of nerve cells declines,
each cell has fewer dendrites, and some demyelinization of the cells occurs.
These changes slow nerve conduction. Response and reaction times are
slower; reflexes become weaker.
Plaques, tangles, and atrophy occur in the brain to varying degrees;
there is not always a relationship between these changes and cognitive
function. Free radicals accumulate with age and may have a toxic effect on
certain nerve cells. Cerebral blood flow decreases about 20% as fatty
deposits gradually accumulate in the blood vessels, and decreases are even
greater in persons with small-vessel cerebrovascular disease due to diabetes
and hypertension; this contributes to an increased risk of strokes. The brain
has a greater ability to compensate after injury than does the spinal cord,
but this ability to compensate declines with age.
Intellectual performance tends to be maintained until at least age 80 in
the absence of neurologic or vascular disease, although a slowing in central
processing delays the time required to perform tasks. Verbal skills are well
maintained until age 70, after which there is a gradual reduction in
vocabulary, a tendency to make semantic errors, and abnormal prosody
(rhythm and intonation). Other age-related changes in intellectual function
are subtle but can be detected as difficulty learning, especially languages,
and forgetfulness in noncritical areas.
The general lack of replacement of neurons affects the sensory organs’
function, which becomes less acute with age. The number and sensitivity of
sensory receptors, dermatomes, and neurons decrease, resulting in dulling
of tactile sensation. There is also some decline in the function of cranial
nerves mediating taste and smell. Increased levels of taste, sound, scents,
touch, and lighting are required for perception by older persons as
compared with younger adults.
It must be remembered that these changes do not affect all individuals
similarly. Genetic makeup, diet, lifestyle practices, and other factors
influence the health and function of the neurologic system.
NEUROLOGIC HEALTH PROMOTION

Many neurologic disorders occur for reasons beyond one’s control, but
some can be prevented or minimized. For instance, cigarette smoking,
obesity, ineffective stress management, elevated cholesterol, and
hypertension are significant risk factors for neurovascular disease. The risk
of injury to the head and spinal column is increased with unsafe actions,
such as failure to use seatbelts, incompetent driving skills, alcohol and drug
abuse, and falls. Infections of the ear or sinuses and sexually transmitted
infections can lead to neurologic dysfunction. Most of these factors are
within an individual’s control to prevent. Nurses can educate persons of all
ages in preventive measures that promote neurologic health in late life.
KEY CONCEPT
Maintaining weight and cholesterol levels within their ideal range,
avoiding cigarette smoking, effectively managing stress, driving safely,
and controlling infections can prevent some neurologic conditions.
The close relationship and regular contact nursing staff have with
patients puts them in an ideal position to detect new or subtle symptoms of
neurologic diseases that otherwise may be missed (Box 22-1). Recognizing
symptoms and taking prompt action to ensure that patients are evaluated in
a timely manner can help prevent irreversible or serious dysfunction.
BOX 22-1 Subtle Indications of Neurologic

Problems
New headaches that occur in the early morning or interrupt sleep
Change in vision (e.g., sudden decreased acuity, double vision, and
blindness in portion of visual field)
Sudden deafness, ringing in ears
Mood, personality changes
Altered cognition or level of consciousness
Clumsiness, unsteady gait
Numbness, tingling of extremity
Unusual sensation or pain over nerve
In addition, nursing assessment of neurologic function (Assessment

Guide 22-1) can help reveal specific problems that warrant intervention.
Table 22-1 lists nursing problems the nurse may identify through
assessment.
TABLE 22-1 Nursing Problems Related to Neurologic

Problems

NEUROLOGIC FUNCTION
GENERAL OBSERVATIONS AND INTERVIEW
Keen observation while interviewing the patient can aid in detecting a
variety of neurologic problems:
On initial inspection of the patient, observe for asymmetry, deformity,
weakness, paralysis, tremors, and other abnormalities.
Explore the presence of symptoms of neurologic disorders, such as
pain, tingling sensations, numbness, blackouts, headaches, twitching,
seizures, sleep disturbances, dizziness, distortions of reality,
weakness, and changes in mental status.
If clinical abnormalities or symptoms are identified, inquire into their
origin, length of time present, and resulting limitations or problems.
SPEECH ASSESSMENT
During something as basic as simple introductions, speech disorders can
become evident. If speech problems exist, it is important to differentiate
problems with articulation (i.e., dysarthria ) and problems with the use of
symbols (i.e., dysphagia):
With dysarthria, the symbols (in this case, words) are used correctly,
but speech may be slurred or distorted as a result of poor motor
control. Subtle dysarthrias can be disclosed by asking the patient to
pronounce the following syllables:
me, me, me (to test the lips)la, la, la (to test the tongue)ga, ga, ga (to
test the pharynx)
Dysphasias can be receptive, expressive, or a combination of both:
To test for a receptive aphasia, ask the patient to follow a command
(e.g., pick up the pencil); the patient’s inability to understand what
these symbols mean will prevent the command from being followed.
The patient with expressive aphasia will be able to understand
commands but will not be able to put symbols together into an
intelligent speech form. Point to several objects and ask the patient to
name them; mild dysphasias (i.e., paraphasia) may be noted if the
patient substitutes a close, although inaccurate, word for the right
one, such as calling a shoe a boot or a watch a clock.
The ability to understand and express oneself through the written
word is important to evaluate also. Ask the patient to write a short
sentence that you dictate and to read a sentence from a newspaper.
Ensure that the patient has the educational and visual abilities to
fulfill these demands.
Sensation
Ask the patient to close his or her eyes and to describe the sensations felt.
To help document areas where problems are identified, a figure drawing
may prove useful.
Touch various parts of the body (e.g., forehead, cheeks, arms, hands,
legs, and feet) lightly with your finger or a cotton wisp and note if the
patient is able to feel the sensations. Compare analogous areas on
both sides of the body and distal and proximal areas on the same
extremity.
If these primary sensations are intact, test the patient’s ability to
identify two simultaneous stimuli (e.g., touch the right cheek and the
left forearm).
To test cortical sensation (i.e., stereognosis), have the patient, again
with closed eyes, identify various objects placed in each hand (e.g.,
key, marble, and coin). The inability to sense these objects is known
as astereognosis.
Coordination and Cerebellar Function

Hold up your finger and ask the patient to touch it and then touch his
or her nose; have the patient continue this action as you move your
fingers to different areas. Do this point-to-point testing with both
arms of the patient, and note uneven, jerking movements and the
inability to touch your finger or his or her nose.
To test coordination in the lower extremity, have the patient lie down
and run the heel of one foot against the shin of the other leg.
Test the ability to make rapid alternating movements by having the
patient rapidly tap his or her index finger on the thigh or a table
surface.
Tandem walking, in which the patient walks heal to toe as though
walking a tightrope, also tests coordination; patients with arthritic
deformities may not be able to perform this test. Have weak or poorly
coordinated patients hold your hand during the tandem walking test.
Reflexes
Nurses can perform some tests of reflexes:
To test the corneal reflex, gently touch the cornea with a wisp of
clean cotton. Tissue and gauze are too rough and can cause corneal
abrasions. Normally, the eye should blink.
Test the Babinski reflex (i.e., plantar response) by stroking the sole of
the patient’s foot. Normally, the toes should flex; an abnormal
response is extension and fanning of the toes.
Additional Tests
Each of the cranial nerves can be tested to identify further problems.
Lumbar puncture, cerebral angiography, pneumoencephalography, and
computed tomography scans are among other screening devices used to
evaluate neurologic problems. A review of mental status is included in the
assessment of the nervous system. (For information on mental status
examination, refer to Chapter 29.)

Poor positioning results in discomfort and pain that can be remedied by
altering the patient’s position, making pain the most appropriate nursing
problem associated with poor positioning in the older client.
POINT TO PONDER
Review your health status and lifestyle for risk factors for neurologic
disorders. If risks are present, how can you reduce them?
SELECTED NEUROLOGIC
CONDITIONS
Selected neurologic conditions that nurses may see in older adults are
discussed in the following sections. A discussion of Alzheimer’s disease, a
neurodegenerative condition, is provided in Chapter 30.
Parkinson’s disease affects the ability of the central nervous system to
control body movements as a result of impaired function of basal ganglia in
the midbrain. It occurs when neurons that produce dopamine in the
substantia nigra die or become impaired. Dopamine is necessary for smooth
motor movement and has a role in emotions. With the damage of a
significant number of these dopamine-producing cells, the symptoms of
Parkinson’s disease appear.
Parkinson’s disease is more common in men and occurs most frequently
after the fifth decade of life. The incidence rises with age, although most
cases have been diagnosed by the time people reach their seventh decade of
life. Although its exact cause is unknown, this disease is thought to be
associated with a history of exposure to toxins, encephalitis, and
cerebrovascular disease, especially arteriosclerosis. A finding in people
with Parkinson’s disease compared with individuals who have other causes
of tremors is the presence of the Lewy body, an intracellular inclusion body,
in the brain. The death of substantia nigra cells within the basal ganglia
leads to a significant reduction in dopamine, which is responsible for the
symptoms.
A faint tremor in the hands or feet that progresses over a long time may
be the first clue to Parkinson’s disease (Fig. 22-1). The tremor is reduced
when the patient attempts a purposeful movement. Muscle rigidity and
weakness develop, evidenced by drooling, difficulty in swallowing, slow
speech, and a monotone voice. The patient’s face assumes a masklike
appearance, and the skin is moist. Bradykinesia (slow movement) and poor
balance occur. Appetite frequently increases, and the person may
demonstrate emotional instability. Postural instability is present. A
characteristic sign is a shuffling gait while leaning forward at the trunk. The
rate of movement increases as the patient walks, and the patient may not be
able to voluntarily stop walking. As the disease progresses, the patient may
become entirely unable to ambulate. Secondary symptoms include
depression, anxiety, sleep disturbances, dementia, forced eyelid closure,
decreased blinking, drooling, dysphagia, constipation, shortness of breath,
urinary hesitancy, urgency, and reduced interest in sex. In a national survey
of people with Parkinson’s disease, it was discovered that nonmotor
symptoms were responsible for poor quality of life to a greater extent than
motor symptoms (Tarolli et al., 2020). This emphasizes the importance of
preventing and treating all of the potential effects of the disease.
FIGURE 22-1 Tremors and shuffling gait are
characteristic of Parkinson’s disease.
A variety of measures are used to control the tremors and maintain the
highest possible level of independence. Carbidopa/levodopa in the form of
Sinemet combines levodopa, which converts to dopamine, and carbidopa,
which reduces adverse effects and is the most widely used and effective
drug for Parkinson’s disease. Dopamine agonists directly stimulate
dopamine receptors; they usually are introduced gradually and titrated to a
therapeutic dose to reduce the risk of adverse reactions. Although their use
has declined, anticholinergics may be prescribed to decrease the amount of
acetylcholine in the brain to restore the normal neurotransmitters’ balance;
the effects of these drugs need to be closely monitored because they can
exacerbate glaucoma and cause temporary anuria. Amantadine, mono
oxidase inhibitors, and catechol-O-methyltransferase inhibitors also can be
prescribed to control symptoms. Close monitoring of drug therapy is
important. While they are taking levodopa, patients should avoid foods that
are high in vitamin B6, such as avocados, lentils, and lima beans, because
they will counteract the drug; dietary restrictions are not necessary if the
patient is taking carbidopa–levodopa (Sinemet). Deep brain stimulation has
become the surgical treatment of choice because it is effective, does not
destroy brain tissue, is reversible, and can be adjusted as the disease
advances (National Institutes of Health, 2018). Drug infusion systems and
gene therapy are among the other therapies that may benefit some people
who have Parkinson’s disease; the neurologist should be consulted
regarding the potential usefulness to the patient.
Active and passive range-of-motion exercises maintain and improve
joint mobility; warm baths and massage may facilitate these exercises and
relieve muscle spasms caused by rigidity. Contractures are a particular risk
of older persons with Parkinson’s disease. Physical and occupational
therapists should be actively involved in the exercise program to help the
patient find devices that increase self-care ability. Surgical intervention is
rare for older patients because they do not tend to respond well.
Tension and frustration will aggravate the patient’s symptoms;
therefore, it is important for the nurse to offer psychological support and
minimize emotional upsets. Educating about the disease and its
management helps patients and their families gain realistic insights. The
nurse should emphasize that the disease progresses slowly and that therapy
can minimize the disability. Although intellectual functioning may be
impaired as the disease progresses, the person with Parkinson’s disease
cannot be assumed to be cognitively impaired; it is important that others do
not underestimate the mental abilities of the patient due to the speech
problems and helpless appearance, as this can be extremely frustrating and
degrading to the patient, who may react by becoming depressed or irritable.
Continuing support by the nurse can help the family maximize the patient’s
mental capacity and understand personality changes that may occur.
Communication and mental stimulation should be encouraged on a level
that the patient always enjoyed.
As the disease progresses, the patient requires increased assistance.
Skillful nursing assessment is essential to ensure that the demands for
assistance are met while the maximum level of patient independence is
preserved. The nurse should also assess family caregivers for stress and
fatigue.

Transient ischemic attacks (TIAs) are temporary or intermittent
neurological events that can result from any situation that reduces cerebral
circulation. Hyperextension and flexion of the head, such as when an
individual falls asleep in a chair, can impair cerebral blood flow. Reduced
blood pressure resulting from anemia and certain drugs (e.g., diuretics and
antihypertensives) and cigarette smoking, due to its vasoconstrictive effect,
will also decrease cerebral circulation, as will sudden standing from a prone
position. Hemiparesis , hemianesthesia, aphasia, unilateral loss of vision,
diplopia, vertigo, nausea, vomiting, and dysphagia are among the
manifestations of a TIA, depending on the location of the ischemic area.
These signs can last from minutes to hours, and complete recovery is usual
within a day. Treatment may consist of correction of the underlying cause,
anticoagulant therapy, or vascular reconstruction. A significant concern
regarding TIAs is that they increase the patient’s risk of sustaining a
cerebrovascular accident (CVA).
KEY CONCEPT
Good alignment and support of the head and neck can prevent
hyperextension and flexion of the head that can lead to impaired cerebral
blood flow.
CVAs are the third leading cause of death and a major cause of disability in
older adults. Older persons with hypertension, severe arteriosclerosis,
diabetes, gout, anemia, hypothyroidism, silent myocardial infarction, TIAs,
and dehydration and those who smoke are among the high-risk candidates
for a CVA. The major types of CVA are ischemic, usually resulting from a
thrombus or embolus, and hemorrhagic, which can occur from a ruptured
cerebral blood vessel. Most CVAs in older individuals are ischemic, caused
by partial or complete cerebral thrombosis. Light-headedness, dizziness,
headache, drop attack (feeling of being strongly and suddenly pulled to the
ground), and memory and behavioral changes are some of the warning
signs of a CVA. A drop attack is a fall caused by a complete muscular
flaccidity in the legs but with no alteration in consciousness. Patients
describing or demonstrating these symptoms should be referred for prompt
medical evaluation. Because nurses are in a key position to first learn of
these signs, they can be instrumental in helping the patient avoid disability
or death from a stroke. CVAs can occur without warning, however, and
show highly variable signs and symptoms, depending on the area of the
brain affected. Major signs tend to include hemiplegia , aphasia, and
hemianopsia .
Although older adults have a higher mortality rate from CVAs than the
young, those who do survive have a good chance of recovery. Good nursing
care can improve the patient’s chance of survival and minimize the
limitations that impair a full recovery. In the acute phase, nursing efforts
have the following aims:
Maintain a patent airway.

Provide adequate nutrition and hydration.
Monitor neurologic and vital signs.
Prevent complications associated with immobility.
The National Institutes of Health Stroke Scale (NIHSS) is

recommended by the Joint Commission, the American heart Association,
and the American Stroke Association as a means to assess neurologic status
following a stroke. (A copy of the tool can be viewed at
https://www.stroke.nih.gov/documents/NIH_Stroke_Scale_508C.pdf.)
Although there are recommended assessment frequencies (e.g., upon
admission or transfer, daily, when there are neurological changes), new
recommendations suggest that nurses use critical thinking skills to
determine how frequently the NIHSS assessment should be done (Wells-
Pittman & Gullicksrud, 2020).
Unconscious patients need good skin care and frequent turning because
they are more susceptible to pressure injury. If an indwelling catheter is not
being used, it is important for the nurse to examine the patient for
indications of an overdistended bladder and promptly remedy the situation
if it occurs. The eyes of the unconscious patient may remain open for a long
time, risking drying, irritation, and ulceration of the cornea. Corneal
damage can be prevented by eye irrigations with a sterile saline solution
followed by the use of sterile mineral oil eye drops. Eye pads may be used
to help keep the eyelids closed; these are changed daily and frequently
checked to make sure the lids are actually closed. Regular mouth care and
range-of-motion exercises are also standard measures.
POINT TO PONDER
How would your life and the lives of your family members be affected if
you suffered a stroke?
When the patient regains consciousness and stabilizes, more active

nursing efforts can focus on rehabilitation. It may be extremely difficult for
patients to understand and participate in their rehabilitation because of
speech, behavior, and memory problems. Although these problems vary
depending on the side of the brain affected, some general observations can
be noted. Attention span is reduced, and long, complicated directions may
be confusing. Memory for old events may be intact, whereas recent events
or explanations are forgotten, a characteristic demonstrated by many older
persons without a history of CVA. Patients may have difficulty transferring
information from one situation to another. For example, they may be able to
remember the steps in lifting from the bed to the wheelchair but be unable
to apply the same principles in moving from the wheelchair to an armchair.
Confusion, restlessness, and irritability may arise from sensory deprivation.
Emotional lability may also be a problem. To minimize the limitations
imposed by these problems, the nurse may find the following actions
helpful:
Talk to the patient during routine activities.

Briefly explain the basics of what has occurred, the procedures being
performed, and the activities to expect.
Speak distinctly but do not shout.
Devise an easy means of communication, such as a picture chart to
which one can point.
Minimize environmental noise, traffic, and clutter.
Aim for consistency of those providing care and of care activities.
Use objects familiar to patients (e.g., their own clothing and clock).
Keep a calendar or sign in the room showing the day and date.
Supply sensory stimulation through conversation, radio, television,
wall decorations, and objects for patients to handle.
Provide frequent positive feedback; even a minor task may be a major
achievement for the patient.
Expect and accept errors and failures.
General medical–surgical textbooks provide more detailed guidance in

the care of patients who have suffered a stroke. Local chapters of the
American Heart Association also provide much useful material for the
nurse, the patient, and the family on the topic of stroke. NURSING CARE
PLAN 22-1 outlines care plan considerations for the patient who is
recovering from a stroke.

THE OLDER ADULT WITH A CEREBROVASCULAR
ACCIDENT: CONVALESCENCE PERIOD
Nursing Problem:(1) Inability to meet self-care demands related to
sensory or motor impairment, visual deficits, fatigue, aphasia;(2)
Reduced activity related to depression, poor motivation, prolonged
immobility, fatigue
Nursing Problem: Reduced physical activity related to altered sensory
and motor function
Nursing Problems: (1) Inability to fulfill responsibilities related to loss

of body function, physical changes, role changes; (2) Disrupted family
relationships related to changes in function, dependency on family for
caregiving, ineffective coping
COMMUNICATION TIP
For patients who have suffered speech impairments as a result of their
stroke, it is important to identify the type of impairment that is
present. Patients with dysarthria usually are able to understand speech
but experience difficulty speaking due to poor motor control, whereas
patients with a dysphasia have problems understanding words and/or
expressing themselves verbally. Caregivers and family members need
to understand the type of impairment that is present so they can
communicate effectively. Treating people with dysarthria as though
they don’t understand can be frustrating and insulting to those people,
whereas assuming that people with a dysphasia can understand
because they can pronounce words can be frustrating and unsafe to
those people. To prevent unnecessary frustration for all parties, it is
important for the nurse to provide a realistic explanation of the speech
disorder and to discuss with those who need to communicate with the
patient effective ways to do so.
Nurses should also promote activities that reduce patients’ risk of

stroke. Managing hypertension is important in decreasing fatal and nonfatal
strokes in older adults. Likewise, smoking cessation is helpful. Older
persons who stop smoking could improve cerebral perfusion levels, which
is an important measure in preventing strokes.
KEY CONCEPT
Controlling hypertension is important in reducing stroke risk in older
adults.
GENERAL NURSING
CONSIDERATIONS FOR
NEUROLOGIC CONDITIONS
Older patients with neurologic conditions face limitations imposed by both
the disease and the aging process. Skillful and creative nursing assistance
can help patients achieve maximum levels of independence. Some assistive
devices—such as rails in the hallways, grab bars in bathrooms, and
numerous other household modifications—can extend the time that patients
can live independently in the community. Periodic home visits by a nurse,
regular contact with a family member or friend, and a daily call from a local
telephone reassurance program can help the patient feel confident and
protected, which promotes independence. Although these individuals may
perform tasks awkwardly and slowly, family members need to understand
that allowing independent function is physically and psychologically more
beneficial than doing tasks for them. Continuing patience, reassurance, and
encouragement are essential to maximize patients’ capacities for
independence.
Personality changes often accompany neurologic problems. Patients
may become depressed as they realize their limitations and become
frustrated by their need to be dependent on others. They may grieve loss of
former roles and identities. Their reactions may be displaced and evidenced
by irritability toward others, often their loved ones or immediate caregivers.
Family members and caregivers may need help in understanding the
reasons for this behavior and in learning effective ways of dealing with it.
Getting offended or angry at such patients may only anger or frustrate them
further. Understanding, patience, and tolerance are needed.
KEY CONCEPT
Caregivers should be prepared for the personality changes that often
occur in individuals who have neurologic disorders; caregivers may
benefit from nursing support also.
Preventing Injury
Protecting older adults with a neurologic disorder from hazards is
particularly important. Uncoordinated movements, weakness, and dizziness
are among the problems that cause these patients to be at high risk for
accidents. Whether in a health facility setting or the patient’s own home in
the community, the nurse should scrutinize the environment for potential
sources of mishaps, such as loose carpeting, poorly lit stairwells, clutter,
and ill-functioning appliances, as well as the lack of fire warning systems,
fire escapes, tub rails, nonslip tub surfaces, or other safeguards. Safety
considerations also include the prevention of contractures, pressure ulcers,
and other risks to health and well-being. Allowing preventable
complications to hamper progress and compound disability is an injustice to
the patient.
CONSIDER THIS CASE

Mr. J, aged 68 years, experienced a
cerebrovascular accident 1 week ago that left him with right-sided
weakness, aphasia, and incontinence. His wife is eager to have him
discharged from the hospital and to care for him at home. You have heard
her state to Mr. J that he “needn’t worry about a thing because she’ll do
everything that needs to be done and all he has to do is stay in bed and
take it easy.”
THINK CRITICALLY
1. Based on the information provided, what problems Mr. and
Mrs. J face?
2. What goals for the care plan will help them address their needs?
Participation Restrictions and Satisfaction With

Participation in Partners of Patients With Stroke
Source: Cox, V., Schepers, V., Ketelaar, M., van Heugten, C., & Visser-
Melly, A. (2020). Archives of Physical Medicine and Rehabilitation, 101(3),
464–471.
A stroke can result in significant disability for many of the people it
affects. In addition, the caregivers of individuals who have had strokes can
be impacted significantly as a result of the caregiving burdens. For some,
there is the satisfaction of knowing they are making a positive difference in
assisting the person who has experienced the stroke. However, caregivers
may experience negative consequences such as anxiety, depression, and a
reduced social life.
This cross-sectional study examined the type of restrictions caregivers
experienced, their satisfaction with various activities, and the differences
between those who were satisfied and those who were dissatisfied. Patients
and their caregivers were selected from three hospitals and five
rehabilitation centers. Caregivers ranged in age from 51 to 66 years, with
the mean age being 59 years. Nearly 60% were women and half were
employed. Through the assessments and interviews, more than one third
were found to have symptoms of anxiety, and nearly one fourth experienced
symptoms of depression. The major restrictions they reported involved the
quality of their relationship with the patient, being able to go out, and
fulfilling household duties. About half of the caregivers who were
employed reported restrictions related to work activities. Despite these
issues, 70% reported being satisfied with their relationship with the person
they were caring for. The less the caregiving responsibilities restricted their
lives, the greater the caregivers’ level of satisfaction.
It is important for nurses to understand that the care needs of patients
who have experienced strokes, as well as the needs of their caregivers, must
be considered when assessing, planning, and providing care. The well-
being, safety, and rehabilitation of persons with strokes can be greatly
influenced by the actions of their caregivers. As part of discharge planning,
nurses time invest time in instructing caregivers regarding patients’ needs
and reviewing how these responsibilities can affect their ability to continue
employment, maintain social relationships and activities, and relate to the
individuals for whom they are caring. In addition to benefiting the patients,
addressing the needs of the caregivers can prevent new health problems for
them.
PRACTICE REALITIES
Sixty-three-year-old Ms. Trotta works in the billing department of the
hospital where you are employed. One of her coworkers with whom you are
friends shares that he is concerned that “something is going on with Ms.
Trotta.” He describes her as having developed a blank expression and
monotone speech. When she picks up papers her hands shake considerably,
and she does not walk with the same bounce that she once did. He is
uncomfortable discussing his observations with Ms. Trotta but is concerned
for her health. He asks for your help.
Over the next few weeks you sit at the same lunch table as your friend
and Ms. Trotta. You notice the symptoms your friend described and suspect
there could be a neurologic problem.
What would be an appropriate way to address your friend’s concerns
and help Ms. Trotta?

1. Outline the content of a health education program to instruct older
adults on practices that could reduce their risks of neurologic
problems.
2. What factors will worsen the symptoms of the patient with Parkinson’s
disease? What suggestions could you give caregivers to promote
maximum function of this patient?
3. What resources exist in your community to assist patients with
Parkinson’s disease, stroke, or other neurologic disorders?

questions.
A 65-year-old male client presents to the emergency department,

reporting a sudden generalized numbness, weakness of his face, right
arm, and legs that started with mild pain 24 hours ago and has
worsened.Nurse’s Notes
1240: The nurse notices that the client’s hands, arms, legs, jaw, and head
are shaking. His extremities are stiff, movements slow, and gait is
unbalanced. He has an expressive aphagia and dysphagia (he failed his
swallowing evaluation), as evidenced by continuous cough upon
swallowing clear water. Pupils are unequal, slightly edematous, round,
and sluggishly reactive to light accommodation on his right pupil as
compared to his left pupil. The client has a history of Parkinson’s
disease, hypertension (HTN), diabetes, hyperlipidemia, and atrial
fibrillation. The client smokes 1 pack of cigarettes a day and has smoked
for 50 years. He denies drinking alcohol or use of street drugs. His
daughter indicates that the client had similar issues 6 months ago when
he reported weakness, numbness of the right side of his face, his right
arm, his right leg, and slurred speech that lasted for a day but was not as
severe as this. The client’s vital signs are temperature 98.6°F oral
(37.5°C), pulse 82, respiratory rate 20, blood pressure 190/110.
Chapter Summary
Age-related changes of the nervous system can result in slower response
and reaction time, weaker reflexes, and duller sensations. Intellectual
performance normally is maintained until the eighth decade of life, and
verbal skills may begin to show some declines after age 70. Neurological
health can be promoted by managing stress effectively, adhering to safe
practices, and avoiding cigarette smoking, obesity, elevated cholesterol, and
hypertension.
The incidence of Parkinson’s disease increases with age. Beginning
with a faint tremor in the hands or feet that is reduced with purposeful
movement, the disease progresses with muscle rigidity and weakness,
dysphagia, slow speech, a monotone voice, and a masklike appearance to
the face. A shuffling gait while leaning forward at the trunk is a
characteristic sign. Medications, deep brain stimulation, and gene therapy
are among the treatments that can be used.
Transient ischemic attacks are temporary or intermittent neurological
events that can result from any situation that reduces cerebral circulation.
Depending on the location of the ischemic area, hemiparesis,
hemianesthesia, aphasia, unilateral loss of vision, diplopia, vertigo, nausea,
vomiting, and dysphagia may be present. Treatment may consist of
correction of the underlying cause, anticoagulant therapy, or vascular
reconstruction.
Cerebrovascular accidents are serious conditions in older adults, being
the third leading cause of death and a major cause of disability in this
population. Risk factors include smoking, hypertension, severe
arteriosclerosis, diabetes, gout, anemia, hypothyroidism, silent myocardial
infarction, TIAs, and dehydration. Major signs include hemiplegia, aphasia,
and hemianopsia. Good nursing care during the acute phase can improve
the patient’s chance of survival and minimize the limitations that impair a
full recovery. Rehabilitation efforts are initiated when the patient regains
consciousness and stabilizes.
Preventing complications and injuries, realistically building on existing
capacities, and promoting independence are core nursing measures to
individuals with neurological conditions.
Online Resources
American Stroke Association
https://www.stroke.org
American Parkinson Disease Association
https://www.apdaparkinson.org
Epilepsy Foundation
https://www.epilelsy.com
Michael J. Fox Foundation for Parkinson’s Research
https://www.michaeljfox.org
National Institute of Neurological Disorders and Stroke
https://www.ninds.nih.gov
National Multiple Sclerosis Society
https://www.nationalmssociety.org
National Stroke Association
https://www.stroke.org
Paralyzed Veterans of America
https://www.pva.org
Parkinson Alliance
https://www.parkinsonalliance.org
Parkinson Foundation
https://www.parkinson.org
Parkinson’s Resource Organization
https://www.parkinsonsresource.org
References
National Institutes of Health. (2018). Adaptive deep brain stimulation for Parkinson’s disease.
Retrieved April 10, 2020 from https://www.nih.gov/news-events/nih-research-matters/adaptive-
deep-brain-stimulation-parkinsons-disease
Tarolli, C. G., Zimmerman, G. A., Auinger, P., McIntosh, S., Horowitz, R. K., Kluger, B. M., …
Holloway, R. G. (2020). Symptom burden among individuals with Parkinson disease: A national
survey. Neurology Clinical Practice , 10 (1), 65–72.
Wells-Pittman, J., & Gullicksrud, A. (2020). Standardizing the frequency of neurologic assessment
after acute stroke. American Journal of Nursing , 120 (3), 48–54.
CHAPTER 23
Vision and Hearing
Chapter Outline
Effects of Aging on Vision and Hearing
Sensory Health Promotion
Promoting Vision
Promoting Hearing
Assessing Problems
Selected Vision and Hearing Conditions and Related Nursing
Interventions
Visual Deficits
Hearing Deficits
General Nursing Considerations for Visual and Hearing Deficits
LEARNING OBJECTIVES
1. Explain the importance of good vision and hearing and the impact of
visual and hearing deficits on older adults.
2. Describe the effects of aging on vision and hearing.
3. List measures to promote healthy vision and hearing in older adults.
4. Identify signs of and nursing interventions for older adults with
cataracts, glaucoma, macular degeneration, detached retina, corneal
ulcers, and hearing impairment.
TERMS TO KNOW
Cataractclouding of crystalline lens of eye
Glaucomaeye disease involving increased intraocular pressure
Macular degenerationloss of central vision due to the development of
drusen deposits in the retinal pigmented epithelium
Presbycusisage-related high-frequency sensorineural hearing loss
Presbyopiaage-related decrease in eye’s ability to change the shape of
lens to focus on near objects
Good vision and hearing are extremely valuable assets that often are taken
for granted. For instance, people are better able to protect themselves from
harm when they can see, hear, and communicate. The reduced ability to
protect oneself from hazards because of sensory deficits can result in
serious falls from unseen obstacles, missed alarms and warnings, and
ingesting hazardous substances or improper drug dosages due to the
inability to clearly read labels.
The ability to hear and see also facilitates accurate perception of the
environment. People might suspect they are being talked about if they are
unable to hear the conversation of those around them. Poor eyesight can
hamper reading the newspaper and recognizing a familiar face on the street.
One’s surroundings may appear dull and isolated without the ability to see
or hear.
Finally, social interaction, the sharing of experiences, and the exchange
of feelings are more complete when vision and hearing are intact. Through
communication, people share joys and burdens, derive feelings of normalcy,
validate perceptions, and maintain a link with reality.
POINT TO PONDER
How would being blind or deaf affect your daily life? What reactions do
you think you would experience?
EFFECTS OF AGING ON VISION AND
HEARING
One of the most significant areas of changes that occur with age is that
affecting vision. The reduced elasticity and stiffening of the muscle fibers
of the lens of the eye that begins in the fourth decade of life interferes with
the ability to adequately focus and is the factor responsible for most older
people requiring some form of corrective lenses; this condition is known as
presbyopia . Visual acuity progressively declines due to reduced pupil size,
opacification of the lens and vitreous, and loss of photoreceptor cells in the
retina. The light perception threshold decreases causing difficulty with
vision at night and in dimly lit areas. Dark and light adaptation takes longer.
Sensitivity to glare increases due to cataract formation. Cells in the retina
become less sensitive, causing distortions of low tone colors, such as blues
and greens. Visual changes cause depth perception to become distorted,
making the ability to judge the height of walking surfaces more
challenging. Visual fields become smaller reducing peripheral vision. The
eyes produce fewer tears and are drier.
The prevalence of blindness increases with age, with more than half of
all individuals who are identified as legally blind each year being 65 years
of age or older (National Eye Institute, 2020). Visual limitations can make
communication problematic because facial expressions and gestures, which
are as important as the words themselves, may be missed or misinterpreted.
Lip reading to compensate for hearing deficits may be difficult, and written
correspondence may be limited because independent reading and writing
become almost impossible tasks. Remaining aware of current events
through newspapers, and socialization through using social media and
playing cards and other games, may be hampered.
Hearing changes are also common and may negatively impact
communication. Presbycusis (age-related sensorineural hearing loss)
reduces the ability to hear s, sh, f, ph, and w sounds and may cause speech
to be inaudible or distorted, as can impacted cerumen, which is a common
problem in older adults. Older people may be self-conscious of this
limitation and avoid situations in which they must interact. In turn, others
may avoid them because of this difficulty. Telephone conversations can be
affected by this problem, limiting social contact even further for the
individual who may be socially isolated for other reasons. Assessing the
underlying cause of a hearing problem through professional evaluation,
including an audiometric examination, is the first step in the management or
correction of the problem.
POINT TO PONDER
Cellular phones have widespread use. In what ways do you believe these
have both facilitated and impaired communication?
SENSORY HEALTH PROMOTION
Promoting Vision
Despite age-related changes, most older persons have sufficient visual
capacity to meet normal self-care demands with the assistance of corrective
lenses. Serious visual problems can develop, however, and should be
recognized early to prevent significant visual damage. Routine and
thorough eye examinations, including tonometry, by an ophthalmologist are
important in detecting and treating eye problems early in older individuals.
The nurse should stress the importance of an annual eye examination, to
detect vision changes and needs not only for alterations in corrective lenses
but also for early discovery of problems, such as cataracts, glaucoma, and
other disease processes. The nurse must also evaluate the older adult’s
financial ability to afford an eye examination and glasses because health
insurance seldom covers this important service; community resources or the
negotiation of special payment plans may help older adults to acquire the
necessary aid. Medicare may cover eye examinations for people who have
or are at risk for certain conditions.
In addition to annual eye examinations, prompt evaluation is required
for any symptom that could indicate a visual problem, including burning or
pain in the eye, blurred or double vision, redness of the conjunctiva, spots,
headaches, and any other change in vision. The nurse should review the diet
to ensure an adequate intake of nutrients that promote good vision (Box 23-
1). A variety of disorders can threaten the older individual’s vision. For
instance, arteriosclerosis and diabetes can cause damage to the retina, and
nutritional deficiencies and hypertension can result in visual impairment.
Refer to the sections of this book that describe these diseases to understand
the pathophysiology involved.
BOX 23-1 Nutrients Beneficial to Vision

Essential Fatty Acids: Important to healthy retinal function.
Flavonoid: Improves night vision and adaptation to dark; promotes
visual acuity; improves capillary integrity to reduce hemorrhage risk in
diabetic retinopathy.
Vitamin A: Maintains healthy rods and cones in retina.
Vitamin B complex: May prevent elevated levels of homocysteine, which
is associated with vascular problems affecting the retina.
Vitamin C: Promotes normal vision; supplementation may reduce the
risk of cataracts.
Vitamin E: May aid in preventing cataracts; supplementation in large
doses can prevent macular degeneration.
Selenium: May aid in preventing cataracts; supplementation with vitamin
E can reduce visual loss in macular degeneration.
Zinc: Promotes normal visual capacity and adaptation to dark;
supplementation can reduce visual loss in macular degeneration;
deficiency can facilitate cataract development.
Promoting Hearing
Gerontological nurses have a responsibility to help aging persons protect
and preserve their hearing as well. Some hearing deficits in old age can be
avoided by good care of the ears throughout life. Such care should include
prompt and complete treatment of ear infections, prevention of trauma to
the ear (e.g., from a severe blow or a foreign object in the ear), and regular
audiometric examinations.
The nurse should examine an older adult’s ears frequently for cerumen
accumulation. Cerumen removal can be aided by gentle irrigation of the
external auditory canal with warm water or a hydrogen peroxide and water
solution; commercial preparations are also available. A forceful stream of
solution should not be used during this procedure because it can cause
perforation of the eardrum. It is wise for older persons to have assistance
when irrigating ears because dizziness often occurs during the procedure.
Even allowing water to run in the ears during showers or shampoos can aid
in loosening cerumen. Avoid the use of cotton-tipped applicators for
cerumen removal, because they can push the cerumen back into the ear
canal and cause an impaction. Hairpins or similar devices should never be
used.
KEY CONCEPT
Ear irrigations can help to remove cerumen accumulations; however,
care must be taken to protect the older person from the potential
dizziness associated with this procedure.
In addition, it is beneficial for nurses to provide health education about

the effects of environmental noise on hearing and general health. Protection
from exposure to loud noises, such as those associated with factory and
construction work, vehicles, loud music or drums, and explosions, is
important throughout the life; earplugs or other sound-reducing devices
should be used when exposure is unavoidable. Nurses can take an active
role in advocating legislation to control noise pollution and the enforcement
of that legislation.
Assessing Problems
Because it is the rare older individual who does not suffer from some
sensory deficit, it behooves the nurse working with older adults to be skilled
in assessing vision and hearing (Assessment Guide 23-1); to ensure that
sensory problems are properly evaluated; and to implement associated
assistive techniques to promote maximum sensory functioning. Table 23-1
lists some of the nursing problems associated with sensory deficits.
TABLE 23-1 Nursing Problems Associated With Sensory

Deficits

VISION AND HEARING
During interactions with the patient, note the signs of hearing deficits such
as missed communication, requests to have words repeated, reliance on lip
reading, and cocking of the head to one side in an effort to hear better.
Identify eye problems by noticing if the patient uses eyeglasses,
demonstrates difficulty seeing (e.g., bumping into objects and unable to
see small print), or possesses eye abnormalities such as drooping eyelids,
discolored sclera, excess tearing, discharge, and unusual movements of the
eyes. Foul odors (e.g., associated with incontinence or vaginitis) that do
not seem to bother the patient could reflect diminished olfactory function;
cigarette burns on finger or unrecognized pressure ulcers may indicate that
the patient has reduced ability to sense pressure and pain.
INTERVIEW
Ask the patient about the date and type of the last ophthalmic and
audiometric examinations (e.g., Where was the examination done?
Was an ophthalmologist or optometrist seen? Did the eye
examination include tonometry? Was a full audiometric evaluation or
basic hearing screening done?).
If eyeglasses or hearing aids are used, ask questions about where,
when, and how these appliances were obtained (e.g., reading glasses
purchased from the local pharmacy versus prescription glasses;
hearing aid obtained via television advertisement).
Ask questions such as the following to disclose the presence of
sensory problems:
“Has there been any change in your vision? Please describe.”
“Are your glasses as useful to you as they were when you first
obtained them?”
“Do you experience pain, burning, or itching in the eyes?”
“Do you ever see spots floating across your eyes? How often does
this happen and how large and numerous are the spots?”
“Do you ever see flashes of light or halos?”
“Are your eyes ever unusually dry or watery?”
“Do you have difficulty with vision at night, in dimly lit areas, or in
bright areas?”
“Does anyone in your family have glaucoma or other eye problems?”
“Have you noticed any change in your ability to hear? Please
describe.”
“Are certain sounds more difficult for you to hear than others?”
“Do you ever experience pain, itching, ringing, or a sense of fullness
in your ears?”
“Do your ears accumulate a lot of wax? How do you manage this?”
“Is there ever drainage from your ears?”
Eyes
Inspect the eyes for unusual structure, drooping eyelids,
discoloration, and abnormal movement. Loss of elasticity around the
eyes, indicated by bags, is a common finding. Black-skinned persons
may normally have a slight yellow discoloration of the sclera. Note
any lesions on the eyelids.
Palpation of the eyeballs with the eyelids closed can reveal hard-
feeling eyes with extremely elevated intraocular pressure (IOP) and
spongy-feeling eyes with fluid volume deficits.
Perform a gross evaluation of visual acuity by having the patient read
a Snellen chart or various sized lettering on a newspaper. If the
patient is unable to see letters on the chart or newspaper, estimate the
extent of the visual limitation by determining if the patient is able to
see fingers held up before him or can merely make out figures.
To perform a gross test of the visual field, have the patient focus
straight ahead. While facing the patient, bring your finger into the
field of view. Note when the patient indicates seeing your finger
compared with when you are able to see it. If the patient has
restrictions in seeing all portions of the visual field, review the exact
nature of this problem. A blind spot in the visual field (i.e., scotoma)
can occur with macular degeneration, a narrowing of the peripheral
field may be associated with glaucoma, and blindness in the same
half of both eyes (i.e., homonymous hemianopia) can be present in
persons who have experienced a cerebrovascular accident.
Test extraocular movements by having the patient follow your finger
as you move it to various points, horizontally and vertically. Irregular,
jerking eye movements can result from disturbances in cranial nerves
III, IV, or VI.
Ears
Inspection of the ears commonly shows cerumen accumulation,
increased hair growth, and atrophy of the tympanic membrane, which
causes it to appear white or gray.
Cerumen impactions should be noted and removed.
A small, crusted, ulcerated lesion on the pinna can be a sign of basal
or squamous cell carcinoma.
Perform a gross evaluation of hearing by determining the patient’s
ability to hear a watch ticking. Check both ears.
Weber and Rinne tests can be performed to assess sounds at different
frequencies. These tests involve placing a vibrating tuning fork next
to the ear or against the skull; this will stimulate the inner ear to
vibrate. The Rinne tuning fork test helps evaluate a patient’s hearing
ability by air conduction compared with that of bone conduction. The
Weber tuning fork test helps determine a patient’s hearing ability by
bone conduction only, and this test is useful when hearing loss is
asymmetrical.
In addition to presbycusis and conductive hearing losses, ear or upper
respiratory infections, ototoxic drugs, and diabetes can be responsible
for diminishing hearing.
SELECTED VISION AND HEARING

NURSING INTERVENTIONS
Visual Deficits
Cataracts
A cataract is a clouding of the lens or its capsule that causes the lens to
lose its transparency. Cataracts are common in older people because
everyone develops some degree of lens opacity with age. In fact, cataracts
are the leading cause of low vision in older adults. Exposure to ultraviolet B
increases the risk of developing cataracts, emphasizing the importance of
wearing proper sunglasses to protect the eyes. Diabetes, cigarette smoking,
high alcohol consumption, and eye injury are also contributing factors.
Most older adults do have some degree of lens opacity with or without the
presence of other eye disorders.
KEY CONCEPT
Everyone develops some degree of lens opacity with age, although it is
more severe in persons who have had significant exposure to sunlight.
Symptoms
No discomfort or pain is associated with cataracts. At first, visual acuity is
not affected, but as opacification continues, vision is distorted, night vision
is decreased, and objects appear blurred. People may have trouble seeing
street signs while driving and feel that there is a film over the eye.
Eventually, lens opacity and vision loss are complete. Glare from sunlight
and bright lights is extremely bothersome to the affected person; this is due
to the cloudy lens causing light to scatter more than it would in a clear lens.
Nuclear sclerosis develops, causing the lens of the eye to become yellow or
yellow-brown; eventually the color of the pupil changes from black to a
cloudy white. Some individuals may report an improvement in the ability to
see small print and objects (“second sight”), which is due to changes in the
lens that increase nearsightedness.
Treatment and Cataract Surgery

Although surgery to remove the lens is the only cure for a cataract, cataracts
affect people differently. Therefore, the need for surgery must be assessed
based on an individual’s unique situation. Patients with a single cataract
may not necessarily undergo surgery if vision in the other eye is good, and
these individuals should concentrate on strengthening their existing visual
capacity, reducing their limitations, and using the safety measures
applicable to any visually impaired person (Box 23-2). Sunglasses, sheer
curtains over windows, furniture placed away from bright light, and several
soft lights instead of a single bright light source minimize annoyance from
glare. It is beneficial to place items within the visual field of the unaffected
eye, a consideration when preparing a food tray and arranging furniture and
frequently used objects. Regular evaluations of the patient by an
ophthalmologist are essential to detect changes or a new problem in the
unaffected eye.
BOX 23-2 Measures to Compensate for Visual

Deficits in Older Adults
Face the person when speaking.
Use several soft indirect lights instead of a single glaring one.
Avoid glare from windows by using sheer curtains or stained
windows.
Use large print reading material.
Place frequently used items within the visual field.
Avoid the use of low-tone colors and attempt to use bright ones.
Use contrasting colors on doorways and stairs and for changes in
levels.
Identify personal belongings and differentiate the room and
wheelchair with a unique design rather than by letters or numbers.
For most patients, surgery improves vision. Cataract surgery is an

outpatient procedure and older people usually withstand it well.
Gerontological nurses are in a position to reassure older patients and their
families that age is no deterrent to cataract surgery. Patients typically can
resume nonstrenuous activities within a day. The simple surgical procedure
and several weeks of rehabilitation can result in years of improved vision
and, consequently, a life of higher quality. Two types of surgical procedures
are used for removing the lens. Intracapsular extraction is the surgical
procedure of choice for the older patient with cataracts and consists of
removing the lens and the capsule. Extracapsular extraction is a simple
surgical procedure in which the lens is removed and the posterior capsule is
left in place. A common problem with extracapsular extraction is that a
secondary membrane may form, requiring an additional procedure for
discission of the membrane.
The most common method of replacing the surgically removed lens is
the insertion of an intraocular lens at the time of cataract surgery. For older
patients, this method has been more successful than adjusting to a contact
lens or special cataract glasses. The intraocular lens tends to distort vision
less than cataract glasses do and does not require the care of a contact lens.
Some patients do develop complications with a lens implant, such as eye
infection, loss of vitreous humor, and slipping of the implant.
Glaucoma
Glaucoma is a degenerative eye disease in which the optic nerve is
damaged from an above-normal intraocular pressure (IOP). It ranks after
cataracts as a major eye problem in older persons and is the second leading
cause of blindness in this population, accounting for as much as 12% of all
blindness in the United States. Glaucoma tends to occur in people over age
40 and increases in prevalence with age. The prevalence is higher in
African American and Hispanic/Latino individuals than in Caucasians.
Although the exact cause is unknown, glaucoma can be associated with
increased size of the lens, iritis, allergy, endocrine imbalance, emotional
instability, and a family history of this disorder. Drugs with anticholinergic
properties can exacerbate glaucoma due to their effects of dilating the pupil.
An increase in IOP occurs rapidly in acute glaucoma and gradually in
chronic glaucoma.
Acute Glaucoma
With acute glaucoma, also called closed-angle or narrow-angle glaucoma,
the patient experiences severe eye pain, headache, nausea, and vomiting. In
addition to the rapid increased tension within the eyeball, edema of the
ciliary body and dilation of the pupil occur. Vision becomes blurred, and
blindness will result if this problem is not corrected within a day,
emphasizing that this is a medical emergency demanding prompt attention.
The ophthalmologist will examine the eye with an ophthalmoscope and
conduct a visual field test (perimetry). Problem is confirmed by placing a
tonometer on the anesthetized cornea to measure IOP (Fig. 23-1). The
normal pressure is within 12 to 21 mm Hg. A reading between 22 and 25
mm Hg is considered potential glaucoma. Another diagnostic test (i.e.,
gonioscopy) uses a contact lens and a binocular microscope to allow direct
examination of the anterior chamber and differentiate closed-angle from
open-angle glaucoma. In the past, if IOP did not decline within 24 hours,
surgical intervention would be necessary. However, medications are now
effective in treating the acute attack (e.g., carbonic anhydrase inhibitors,
which reduce the formation of aqueous solution; mannitol, urea, and
glycerin, which reduce fluid because of their ability to increase osmotic
tension in the circulating blood). An iridectomy may be performed after the
acute attack to prevent future episodes of acute glaucoma.
FIGURE 23-1 Measuring intraocular pressure by the use
of a tonometer.
Chronic Glaucoma
Chronic, or open-angle, glaucoma is more common than acute glaucoma. It
often occurs so gradually that affected individuals are unaware that they
have a visual problem. Peripheral vision becomes slowly but increasingly
impaired so that people may not realize for a long time why they bump or
knock over items at their side. They may need to change eyeglasses
frequently. As the impairment progresses, central vision is affected. People
may complain of a tired feeling in their eyes, headaches, misty vision, or
seeing halos around lights—symptoms that tend to be more pronounced in
the morning. The cornea may have a cloudy appearance, and the iris may be
fixed and dilated. Although this condition usually involves one eye, both
eyes can become affected if treatment is not sought. The same procedures
as mentioned with acute glaucoma are used to diagnose this problem.
Treatment, aimed toward reducing the IOP, may consist of a combination of
a miotic and a carbonic anhydrase inhibitor or of surgery to establish a
channel to filter the aqueous fluid (e.g., iridectomy, iridencleisis,
cyclodialysis, and corneoscleral trephining). Laser trabeculoplasty can be
used to drain fluid and reduce pressure from the eye.
KEY CONCEPT
Open-angle glaucoma, the most common form of the disease, can be
asymptomatic until an advanced stage; therefore, glaucoma screening is
important.
Care and Prevention of Complications

Vision lost due to glaucoma cannot be restored. However, additional
damage can be prevented by avoiding any situation or activity that increases
IOP. Physical straining and emotional stress should be prevented. Miotics
may be instilled into the eye; acetazolamide may be used. Mydriatics,
stimulants, and agents that elevate the blood pressure must not be
administered. It may benefit patients to carry a card or wear a bracelet
indicating their problem to prevent administration of these medications in
situations in which they may be unconscious or otherwise unable to
communicate. Abuse and overuse of the eyes must also be prevented.
Periodic evaluation by an ophthalmologist is an essential part of the
continued care of the patient with glaucoma.
Patient compliance with treatment for glaucoma can be challenging.
The silent nature of this condition, difficulties with instilling eyedrops, and
the cost of medications contribute to a lack of adherence to the plan of care.
Nurses need to teach patients about the disease and its care and counsel
them about the importance of compliance. The care plan for these patients
needs to include ongoing reinforcement of self-care measures for disease
management. NURSING CARE PLAN 23-1 presents a sample care plan for
the patient with open-angle glaucoma.

THE OLDER ADULT WITH OPEN-ANGLE GLAUCOMA
Nursing Problem: Need for education related to management of disease
Nursing Problem: Risk for injury related to impaired vision and risks
associated with glaucoma
Nursing Problems: Anxiety, fear, and social isolation related to loss of

vision
Macular Degeneration
Macular degeneration , the most common cause of blindness in people
over age 65, affects significantly more older White individuals than other
racial or ethnic groups (National Eye Institute, 2019). It involves damage or
breakdown of the macula, which results in a loss of central vision. The most
common form is involutional macular degeneration, which is associated
with the aging process, although macular degeneration can also result from
injury, infection, or exudative macular degeneration. Figure 23-2 compares
vision loss experienced with cataracts, glaucoma, and macular
degeneration.
FIGURE 23-2 Examples of normal vision, vision with

cataracts, vision with age-related macular degeneration,
and vision with glaucoma. (Images courtesy of the
National Eye Institute, National Institutes of Health.)
KEY CONCEPT
A loss of central vision accompanies macular degeneration.
Routine ophthalmic examinations can identify macular degeneration
and promote treatment that can prevent additional vision loss. Laser therapy
has been used for the treatment of some forms of macular degeneration, but
the involutional type does not respond well to this procedure. Magnifying
glasses, high-intensity reading lamps, and other aids can prove helpful to
patients with this condition.
Detached Retina
Older persons may experience detachment of the retina, a forward
displacement of the retina from its normal position against the choroid. The
symptoms, which can be gradual or sudden, include the perception of spots
moving across the eye, blurred vision, flashes of light, and the feeling that a
coating is developing over the eye. Blank areas of vision progress to
complete loss of vision. The severity of the symptoms depends on the
degree of retinal detachment. There does not tend to be pain.
Prompt treatment is required to prevent continued damage and eventual
blindness. Initial measures most likely to be prescribed, bed rest and the use
of bilateral eye patches, can be frightening to the older patient, who may
react with confusion and unusual behavior. The nurse should help the
patient feel as secure as possible; frequent checks and communication, easy
access to a call light or other means of assistance, and full, honest
explanations will help provide a sense of well-being. After time has been
allowed for the maximum amount of “reattachment” of the retina to occur,
surgery may be planned. Several surgical techniques are used in the
treatment of detached retinas. Electrodiathermy and cryosurgery cause the
retina to adhere to its original attachment; scleral buckling and
photocoagulation decrease the size of the vitreous space. Eye patches
remain on the patient for several days after surgery. Specific routines vary
according to the type of surgery performed. The patient needs frequent
verbal stimuli to minimize anxiety and enhance psychological comfort.
Physical and emotional stress must be avoided. Approximately 2 weeks
after surgery, the success of the operation can be evaluated. A minority of
patients must undergo a second procedure. It is important for the patient to
understand that periodic examination is important, especially because some
patients later suffer a detached retina in the other eye.
Macular degeneration is the loss of central vision, and glaucoma is
indicated by increased intraocular pressure. Cataracts and presbyopia (as
well as presbycusis) are other age-related problems of the eye.
Corneal Ulcer
Inflammation of the cornea, accompanied by a loss of substance, causes the
development of a corneal ulcer, a problem more common in older adults
than in younger-aged individuals. Febrile states, irritation, dietary
deficiencies, lowered resistance, and cerebrovascular accident tend to
predispose the individual to this problem. Corneal ulcers, which are
extremely difficult to treat in older persons, may scar or perforate, leading
to destruction of the cornea and blindness. The affected eye may appear
bloodshot and show increased lacrimation. Pain and photophobia are also
present.
Nurses should advise patients to seek prompt assistance for any
irritation, suspected infection, or other difficulty with the cornea as soon as
it is identified. Early care is often effective in preventing the development
of a corneal ulcer and preserving visual capacity. Cycloplegics, sedatives,
antibiotics, and heat may be prescribed to treat a corneal ulcer. Sunglasses
will ease the discomfort associated with photophobia. It is important that
the underlying cause be treated—an infection, abrasion, or presence of a
foreign body. Corneal transplants are occasionally done for more advanced
corneal ulcers.
Hearing Deficits
A significant number of older people, including a majority of those residing
in nursing homes, have some degree of hearing loss, resulting from a
variety of factors in addition to aging. Exposure to noise from loud music,
jets, traffic, heavy machinery, and guns cause cell injury and loss. The
higher incidence of hearing loss in men may be associated with their more
frequent employment in occupations that subject them to loud noises (e.g.,
truck driving, construction work, heavy factory work, and military service).
Recurrent otitis media and trauma can damage hearing. There are
approximately 200 drugs that may be ototoxic, including aspirin, ibuprofen,
naproxen, bumetanide, ethacrynic acid, furosemide, indomethacin,
erythromycin, streptomycin, neomycin, karomycin, and rauwolfia
derivatives; the delayed excretion of these drugs in many older persons may
promote this effect. Diabetes, tumors of the nasopharynx, hypothyroidism,
syphilis, other disease processes, and psychogenic factors can also
contribute to hearing impairment.
Particular problems affect the ears of the older person (Fig. 23-3).
Vascular problems, viral infections, and presbycusis are often causes of
inner ear damage. In otosclerosis, an osseous growth causes fixation of the
footplate of the stapes in the oval window of the cochlea. This may be a
middle ear problem; it is more common among women and can progress to
complete deafness. Tinnitus, a ringing or other sound in the ear, can be
associated with age-related hearing loss, ear injury, medications, or
cardiovascular disease. If correcting the underlying problem does not
eliminate the tinnitus, medications may be prescribed (e.g., tricyclic
antidepressants, gabapentin, and acamprosate); patients may be taught
coping strategies or offered alternative therapies (e.g., acupuncture,
hypnosis, and supplements) also. Infections of the middle ear are less
common in older individuals; they usually accompany more serious
disorders, such as tumors and diabetes. The external ear can be affected by
dermatoses, furunculosis, cerumen impaction, cysts, and neoplasms.
FIGURE 23-3 Problems affecting the ears of older adults.
Patient Care
Because impaired hearing is associated with social isolation, depression, the
risk of dementia, and a higher mortality rate, nurses should pay serious
attention to this deficit (Johns Hopkins Medicine, 2020). The first action in
caring for someone with a hearing deficit should be to encourage
audiometric examination. Hearing impairment should not be assumed to be
a normal consequence of aging and ignored. It would be most sad and
negligent if the cause of the hearing problem was easily correctable (e.g.,
removal of cerumen or a cyst) but was allowed to limit the life of the
affected individual.
Although sometimes the underlying cause of the hearing problem can
be corrected, frequently, older persons must learn to live with varying
degrees of hearing deficits. It is not unusual for individuals with a hearing
impairment to demonstrate emotional reactions to their hearing deficits.
Unable to hear conversation, patients may become suspicious of those
around them and accuse people of talking about them. Anger, impatience,
and frustration can result from repeatedly unsuccessful attempts to
understand conversation. Patients may feel confused or react
inappropriately on receiving distorted verbal communications. Limited
ability to hear danger and protect themselves may make them feel insecure.
Being self-conscious of their limitation may make them avoid social contact
to escape embarrassment and frustration. Social isolation can be a serious
threat; people sometimes avoid an older person with a hearing deficit
because of the difficulty in communication. Physical, emotional, and social
health can be seriously affected by this deficit. Helping older adults live
with hearing deficits is a challenge but an important responsibility in
gerontological care.
A neighbor should be alerted to the individual’s hearing problem so that
he or she can be protected in an emergency. In an institutional setting, such
patients should be located near the nurse’s station. People with hearing loss
should be advised to request explanations and instructions in writing so that
they receive the full content.
Hearing Aids
Hearing aids can benefit persons with some hearing disorders, but they may
not solve all hearing problems. The otologist can determine if the specific
hearing problem can be improved by using a hearing aid and can
recommend the particular aid best suited to the patient’s needs (Fig. 23-4).
A variety of styles of hearing aids are available, including in the ear, behind
the ear, over the ear, and in the ear canal. A hearing aid should never be
purchased without being specifically prescribed. Sometimes older persons
will attempt to improve hearing by purchasing an aid through a private
party or a mail-order catalog, which often results in disappointment and a
waste of money from an already limited budget. The nurse is in a key
position to educate the older individual on the importance of consulting an
otologist before purchasing a hearing aid.
FIGURE 23-4 Types of hearing aids. A. In-the-ear model.
B. Behind-the-ear model.
KEY CONCEPT
Nurses should advise patients to avoid purchasing a hearing aid without
a complete audiometric examination.
Patients must understand that, even with a hearing aid, their problems
will not be solved. Although hearing will improve, it will not return to
normal. Speech may sound distorted through the aid because when speech
is amplified, so are all environmental noises, which can be most
uncomfortable and disturbing to the individual. Sounds may be particularly
annoying in areas where reverberation can easily occur (e.g., a church or
large hall). Some persons never make the adjustment to a hearing aid and
choose not to wear the appliance rather than to tolerate these disturbances
and distortions. New hearing aid users need support during the adjustment
phase and should be advised to wear the aid for progressively longer
periods each day until comfort is gained and to avoid its use in noisy
environments, such as airports, train stations, and stadiums. The aid must be
checked regularly to ensure that the earpiece is not blocked with cerumen
and that the battery is working. Some suggestions for hearing aid care are
offered in Box 23-3.
BOX 23-3 Hearing Aid Care

Turn the aid off or remove the battery when the aid is not being
worn. Store it in a safe, padded container.
Clean the aid at least weekly. Wipe the aid off and use a toothpick,
pipe cleaner, or pick that may have come with the aid to clean the
channel. Do not use alcohol to clean the aid as this can cause drying
and cracking. Avoid having hairspray, gels, or other chemicals
come in contact with the aid.
Protect the aid from exposure to extreme heat (e.g., hair dryers),
cold weather, or moisture.
When changing the battery, turn off the aid first.
Keep several new batteries available. Typically, a battery will last
about 80 hours.
When used appropriately, hearing aids may correct hearing problems

and allow older individuals to maintain communication and social
relationships. Local chapters of hearing and speech associations and
organizations serving the deaf can provide assistance and educational
materials to those affected by and interested in hearing problems.
CONSIDER THIS CASE
You meet Mr. and Mrs. R as you are

providing influenza vaccines at a local senior center. When Mr. R does not
respond to your questions, his wife, in an impatient manner, tells you that
her husband is not responding because “he can’t hear you and is too
stubborn to get a hearing aid.” Mr. R, sensing his wife’s annoyance with
him and hearing a little of what she is saying comments, “I can hear; she
just talks too low sometimes.”
THINK CRITICALLY
1. Although the time you can spend with the couple during this
encounter is limited, you do want to help. What actions can you take?
What referrals could you make?
2. What quick facts about the importance of hearing screening and
safety issues related to the inability to hear could you share?
GENERAL NURSING
CONSIDERATIONS FOR VISUAL AND
HEARING DEFICITS
To compensate for the multiple sensory deficits older persons may
experience, special attention must be paid to stimulation of all the senses
during routine daily activities. The diet can be planned to include a variety
of flavors and colors. Perfumes, fresh flowers, and scented candles, safely
used, can provide interesting fragrances. In an institutional setting, having a
pot of fresh coffee brewing in the patients’ area can provide a pleasant and
familiar aroma during the early morning hours; likewise, a tabletop oven
can allow for cookie baking and other cooking activities in the patients’
area, providing a variety of stimuli. Different textures can be used in
upholstery and clothing fabrics. Clocks that chime, music boxes, and wind
chimes can vary environmental sounds. The design of facilities for older
people should take into consideration the use of different shapes and colors.
Intellectual stimulation, through conversation, music, and books, for
instance, is also vital.
To compensate for visual limitations, one should face the individual and
exaggerate gestures and facial expressions when speaking. To compensate
for poor peripheral vision, which is common in older people, one should
approach these individuals from the front rather than the side where their
vision is limited and ensure that seating allows for full sight of persons or
objects with which they are interacting. Ample lighting is important and
should be provided by several soft indirect lights rather than a single,
bright, glaring source. Using large print games and playing cards and
telephone dials with enlarged numbers that glow in the dark can promote
interaction. Books and magazines with large print and recordings of current
events and popular literature can provide a source of recreation and a means
of keeping informed.
COMMUNICATION TIP
To compensate for a hearing problem that is not corrected by a hearing
aid, efforts should be made to minimize the limitations caused by the
deficit. When talking with individuals with high-frequency hearing
loss, the speaker should talk slowly, distinctly, and in a low-frequency
voice. Raising the voice or shouting will only raise the sounds to a
higher frequency and compound the deficit. Methods for promoting
more accurate and complete communication include talking into the
less impaired ear, facing the individual when talking, using visual
speech (e.g., sign language, gestures, and facial expressions), allowing
the person to lip read, using a stethoscope to amplify sounds (speaking
into the diaphragm while the earpieces are in the patient’s ears), and
using flash cards, work lists, and similar aids and devices. Cupping the
hands over the less deficient ear and talking directly into the ear may
also be helpful.
Understanding the Hospital Experience of Older

Adults With Hearing Impairment
Source: Funk, A., Garcia, C., & Mullen, T. (2018). American Journal of
Nursing, 118(6), 28–34.
With the high prevalence of hearing loss among older adults, many of
the geriatric patients admitted to hospitals will be hearing impaired. Hearing
loss can affect many aspects of the affected person’s life; however, little is
known about the experiences of hospitalized older adults with impaired
hearing. This study sought to gain a better understanding of the perceptions
of hearing-impaired older adults and measures that could be taken to
improve the nursing care they received during hospitalization.
Study participants were 65 years of age or older with self-reported
hearing loss. To facilitate data collection via interview, persons with
cognitive impairment were excluded from the study. The interviews
revealed three major theses: difficulties with health care communication,
feelings of being passive and vulnerable, and frustration with family. Some
participants admitted that they avoided telling staff about their hearing
difficulty due to embarrassment and not wanting to burden staff.
Participants admitted to deciding whether or not to share their impairment
based on nonverbal cues and the tone of voice of staff. Some participants
who usually wore hearing aids did not bring them to the hospital because
they were afraid of losing them.
There are several implications for nurses from this study. Because the
prevalence of hearing impairment is high among older adults, the nurse
should assess every older patient for hearing impairment. In addition to
asking directly, nurses can observe for signs of possible hearing problems,
such as patients turning the head to one side, ignoring communication, or
giving inappropriate responses to questions. If a hearing impairment is
suspected, a finger rub test could be done in which the patient is asked to
close his or her eyes while the nurse rubs his or her thumb and middle
finger together about six to ten inches from the patient, switching from one
side of the patient to the other several times. If the patient is unable to hear
two out of every three rubs, the nurse should refer the patient for follow-up
testing. Making patients feel comfortable about sharing their hearing
deficits can be beneficial in revealing these problems, as well.
When hearing deficits are present, speak clearly and loudly, without
shouting. Advise patients to inform you if they haven’t heard you clearly.
Show patience to avoid having patients feel they are imposing on you by
asking to have things repeated. Assure patients’ hearing impairments are
evident on the care plan and that all caregivers are informed so that they can
effectively communicate. Also, attempt to discuss with family members
patients’ hearing impairments, including effective ways to accommodate
them and ways to reduce patients’ frustration with them.
PRACTICE REALITIES
Mrs. Wynn has recently been admitted to an assisted living community. At
82 years of age, she is able to function and independently perform most
activities of daily living; however, she has experienced some minor injuries
as a result of bumping into furniture in her room. Once, she tripped when
walking from her dark bedroom to the brightly lighted bathroom during the
night. Mrs. Wynn is frustrated and claims she never had this problem in her
home.
What can be done to assist Mrs. Wynn?

1. What can be done to prevent vision and hearing losses with aging?
2. Why are older adults unaware of the signs of glaucoma?
3. Outline a teaching plan for a patient with newly diagnosed glaucoma.
4. Outline modifications to the average home that could benefit a person
with impaired vision.
5. List assistive devices to promote the independent function of persons
with impaired vision or hearing.
6. Locate resources in your community to assist persons with visual and
hearing impairments.

questions.
Nurse’s Notes
1000: The client indicates that he has been having clouded, blurred
vision “for quite some time now.” He reports more sensitivity to light,
double vision in his right eye, seeing “halos” around lights, and
increasing difficulty with vision at night. The nurse notes halos and glare
on the field of the client’s right’s eye. The client has a history of hearing
impairment, diabetes, benign prostatic hypertrophy (BPH), and
hypertension. He is prescribed tamsulosin 0.4 mg and lisinopril 5 mg
daily. The client self-medicates with aspirin (81 mg tablet) daily. His
body mass index (BMI) is 35%; he has smoked 2 packs of cigarettes a
day for over 30 years. His skin is dry, warm, and intact upon skin
assessment. The primary care provider referred the client to an
ophthalmologist. The client’s vital signs are temperature 98.6°F oral
(37.5°C), pulse 74, respiratory rate 22, blood pressure 132/90.
Chapter Summary
A variety of intrinsic and extrinsic factors, including alterations during the
aging process, excessive use and abuse of certain medications, and the
disease processes that affect all age groups, contributes to the vision and
hearing problems of older adults. These deficits compound other problems
that threaten the health, well-being, and independence of older persons—
their increased vulnerability to accidents, their social isolation and declining
physical function, and many other limitations regarding self-care activities.
Gerontological nurses must be aware of the factors that influence sensory
function in older adults and help to ensure that vision and hearing problems
are properly evaluated and corrected when possible.
Online Resources
Alexander Graham Bell Association for the Deaf
https://www.agbell.org
American Council of the Blind
https://www.acb.org
American Speech-Language-Hearing Association
https://www.asha.org
Blinded Veterans Association
https://www.bva.org
Glaucoma Research Foundation
https://www.glaucoma.org
Guide Dogs for the Blind
https://www.guidedogs.com
Guiding Eyes for the Blind
http://www.guiding-eyes.org
International Hearing Dog
https://hearingdog.org
Leader Dogs for the Blind
https://www.leaderdog.org
Lighthouse Center for Vision Loss
https://www.lcfvl.org
National Association for the Deaf
https://www.nad.org
National Braille Association
https://www.nationalbraille.org
National Federation of the Blind
https://www.nfb.org/
National Library Service for the Blind and Print Disabled
https://www.loc.gov/nls
References
Johns Hopkins Medicine. (2020). The hidden risks of hearing loss. Retrieved April 15, 2020 from
https://www.hopkinsmedicine.org/health/wellness-and-prevention/the-hidden-risks-of-hearing-
loss
National Eye Institute. (2019). Age-related macular degeneration (AMD) data and statistics.
Retrieved April 15, 2020 from https://www.nei.nih.gov/learn-about-eye-health/resources-for-
health-educators/eye-health-data-and-statistics/age-related-macular-degeneration-amd-data-and-
statistics
National Eye Institute. (2020). Blindness tables. Retrieved April 10, 2020 from
https://www.nei.nih.gov/learn-about-eye-health/resources-for-health-educators/eye-health-data-
and-statistics/blindness-data-and-statistics/blindness-tables
CHAPTER 24
Endocrine Function
Chapter Outline
Effects of Aging on Endocrine Function
Selected Endocrine Conditions and Related Nursing Considerations
Diabetes Mellitus
Hypothyroidism
Hyperthyroidism
LEARNING OBJECTIVES
1. Summarize the effects of aging on endocrine function.

2. Describe unique manifestations of diabetes in older adults.
3. Outline a teaching plan for the older person with diabetes.
4. List symptoms of hypothyroidism and hyperthyroidism in older adults.
5. Identify appropriate medications for an older adult with diabetes with
risks and benefits.
6. Identify appropriate medications for an older person with
hypothyroidism and hyperthyroidism.
TERMS TO KNOW
Dupuytren’s contracturefixed flexion of the hands due to a thickening of
the fibrous tissue under the skin of the palm and fingers, a risk for
persons with diabetes mellitus
Goiternonmalignant swelling of the thyroid gland
Metabolic syndromegroup of conditions (high triglycerides, low high-
density lipoprotein, elevated fasting blood sugar, elevated blood
pressure, and central obesity) occurring together that increase the risk
of diabetes, stroke, and coronary artery disease
The endocrine system enables the body to grow and develop, reproduce,
metabolize energy, maintain homeostasis, and respond to stress and injury.
This complex system consists of glands that synthesize and secrete
hormones—substances that are transported from glands through the blood
to targeted tissues where they exert specific effects either directly or
indirectly by interacting with specific cell receptors. There are two major
classes of hormones: steroids and thyronines, which are lipid soluble, and
polypeptides and catecholamines, which are water soluble. With aging, the
endocrine system experiences changes that can be diverse and interrelated
in that some changes are compensatory responses for others. Knowledge of
these changes and their effects is beneficial in interpreting symptoms and
advising older adults regarding practices to promote optimal health.
EFFECTS OF AGING ON ENDOCRINE

FUNCTION
With age, the thyroid gland progressively atrophies and thyroid gland
activity decreases, resulting in a lower basal metabolic rate, reduced
radioactive iodine uptake, and less secretion and release of thyrotropin.
Thyroid activity can be further reduced by diminished adrenal function.
Despite these changes, thyroid function remains adequate to meet daily
needs. Adrenocorticotropic hormone secretion decreases with age, which in
turn reduces the secretory activity of the adrenal gland, which reduces the
secretion of estrogen, progesterone, androgen, 17-ketosteroids, and
glucocorticoids. The volume of the pituitary gland decreases with age;
somatotropic growth hormone blood levels may be reduced. Insulin
secretion is also affected by age; there is insufficient release of insulin by
the β cells in the pancreas and reduced tissue sensitivity to the circulating
insulin. Many older adults have reduced ability to metabolize glucose,
particularly when a sudden high concentration of glucose is consumed.
Endocrine health promotion includes giving attention to these effects of
aging and any symptoms of endocrine dysfunction in older adults to
facilitate intervention and treatment.
SELECTED ENDOCRINE
NURSING CONSIDERATIONS
Diabetes Mellitus
A blend of various knowledge and skills is required when caring for older
adults who have diabetes. Type 2 diabetes is the sixth leading cause of death
among older adults (Heron, 2019). Diabetes affects 26.8% of the older
population (Centers for Disease Control and Prevention, 2020). There is a
particularly high prevalence among African Americans, and Mexican
Americans who are 65 years of age and older. Data from The National
Health and Nutrition Examination Survey (NHANES) 2003 to 2014
identified higher HbA1c in non-Hispanic African Americans and Mexican
Americans. This elevated HbA1c can be a predictor of poor outcomes
(Smalls, Ritchwood, Bishu, & Egede, 2020). In data from 2013 to 2014,
32% of older non-Hispanic African Americans were diagnosed with
diabetes and only 21% of all older adults developed diabetes in the United
States (Administration for Community Living, 2017). Consequently, nurses
must be adequately informed of how the detection and management of
diabetes in older adults differs from that in other age groups and health
disparities among different ethnic groups.
Glucose intolerance is a common occurrence among older adults;
several explanations are offered for this. At one time, it was thought that a
physiologic deterioration of glucose tolerance occurred with increasing age;
however, increased amounts of fat tissue present in older persons who are
obese and inactive are now considered significant to the development of
this condition. This may be a factor in the high incidence of diabetes
throughout the general population. Also, diagnostic techniques have been
improved, enabling more persons with the condition to be detected.
Regardless of the reason, it is agreed that different standards must be
applied in evaluating glucose tolerance in older adults.
Obesity, inactivity, an increased amount of fat tissue, and having a first-
degree relative with the disease are the most important contributors to
diabetes mellitus. Physiologic deterioration of glucose tolerance is no
longer considered a risk factor.
KEY CONCEPT
Obesity and low levels of physical activity contribute to the high
prevalence of diabetes mellitus.
Diagnosis
Early diagnosis of diabetes in older persons is often difficult. The classic
symptoms of diabetes may be absent, leaving nonspecific symptoms as the
only clues. For this reason, the ADA advises screening with the use of
fasting blood sugar every 3 years for persons over 45 years of age. The
endocrine society with support from several other agencies advises to
screen the asymptomatic older adult (65 years old and older) with a fasting
blood glucose (FBG) and/or HbA1c. If the levels of the testing are out of
range, the glucose tolerance test would be appropriate (Leroith et al., 2019).
Some indications of diabetes in older adults include orthostatic
hypotension, periodontal disease, stroke, gastric hypotony, impotence,
neuropathy, confusion, glaucoma, Dupuytren’s contracture , and
infection. Laboratory tests, as well as symptoms, may be misleading.
Because the renal threshold for glucose increases with age, older
individuals can be hyperglycemic without evidence of glycosuria, thus
limiting the validity of urine testing for glucose.
Among all the diagnostic measures, the glucose tolerance test is the
most effective. To avoid a false-positive diagnosis, more than one test
should be performed unless there is overt hyperglycemia. The American
Diabetes Association recommends that a minimum of 150 g of
carbohydrates be ingested daily for several days before the test; older,
malnourished individuals may be prescribed 300 g. Recent periods of
inactivity, stressful illness, and inadequate dietary intake should be
communicated to the physician because these situations can contribute to
glucose intolerance. In such circumstances, more accurate results can be
obtained if the test is postponed for 1 month after the episode. Nicotinic
acid, ethacrynic acid, estrogen, furosemide, and diuretics can decrease
glucose tolerance and should not be administered before testing.
Monoamine oxidase inhibitors, propranolol, and high dosages of salicylates
may lower blood sugar levels and interfere with testing. Standard nursing
measures are applied during glucose tolerance testing of older adults. If
unusual symptoms such as confusion develop during the test, it is important
to tell the physician.
The diagnosis of diabetes is usually established if one of the following
criteria exists:
1. Symptoms of diabetes and a random blood glucose concentration ≥200

mg/dL.
2. Glycosylated hemoglobin (HbA1c) ≥6.5%.
3. Fasting blood glucose concentration ≥126 mg/dL (8-hour fast).
4. Blood glucose concentrations 2 hours after an oral glucose intake ≥200
mg/dL during an oral glucose tolerance test. The test should be
performed as described by the World Health Organization, using a
glucose load containing the equivalent of 75 g anhydrous glucose
dissolved in water.
These results are usually confirmed by repeat testing on a different day.
Management of the Illness

As drug therapy to control hyperglycemia is used with most older persons
with diabetes, careful attention to patient education, compliance with the
prescribed plan, and monitoring are essential.
KEY CONCEPT
Although the glycemic goals need to be individualized for the patient,
the general recommendations are for the patient to achieve a fasting
plasma glucose of 90 to 140 mg/dL (ADA), postprandial glucose of less
than 180 mg/dL, and hemoglobin A1c of less than 7.5% or even higher.
(See Table 1 of Kirkman et al., 2012, titled Framework for Considering
Treatment Goals for Glycemia, Blood pressure, and Dyslipidemia in
Older Adults With Diabetes.)
Patient Education.
Once the diagnosis has been confirmed, the nurse should establish a
teaching plan (Box 24-1). Diabetes is known as a serious and chronic
problem to most lay individuals, and being diagnosed with this disease can
be frightening. Fear and anxiety can interfere with the learning process for
older people with newly diagnosed diabetes, who may have witnessed the
crippling or fatal effects of diabetes in others and anticipate such
occurrences in themselves. Having lived through a period in which diabetes
was not successfully managed and was often severely disabling or fatal, the
older individual may not be aware of the advances in diabetes management.
BOX 24-1 Content for Diabetic Patient

Education
GENERAL OVERVIEW
Definition and description of diabetes mellitus
Basic anatomy and physiology
Basic metabolism of nutrients
Impact of advanced age on glucose metabolism, presentation of
symptoms, complications
NUTRITION
Food groups, food exchange system
Dietary requirements
Consistent pattern of food intake
Menu plans
Understanding food labels
Flexibility of diet
ACTIVITY AND EXERCISE

Coordination and goal setting with the health care provider
Planning exercise in relation to glucose levels
Precautions
Monitoring glucose, vital signs
Recognizing complications
Importance of good fluid intake
MEDICATIONS
Actions
Dosage
Proper administration
Precautions
Adverse effects
Interactions
MONITORING
Purpose, goals
Types
Procedure
RECOGNIZING HYPOGLYCEMIA AND

HYPERGLYCEMIA
Description and definition of hypoglycemia and hyperglycemia
Prevention
RECOGNITION OF SYMPTOMS
Actions to take for each
Signs that warrant contacting the health care provider
PREVENTION OF COMPLICATIONS
Foot care
Eye examinations
Cardiac evaluations
Blood pressure monitoring
Glucose monitoring
Adjustments for diabetes care during illnesses
Recognition of complications (e.g., infections, nephropathy, cardiac
events, wound care, and neuropathies)
Older people may be depressed or angry that this disease threatens to

reduce the quality of the remainder of their lives; they may question the
value of exchanging an unrestricted lifestyle for a potentially longer but
restricted one. Concerns may arise about how a special diet and medications
will be afforded on an already limited budget. Social isolation may develop
from fear of becoming ill in public or facing restrictions that make them
different from their peers. They may question their ability to manage their
diabetes independently and worry that institutionalization will be necessary.
Such concerns must be recognized and dealt with by the nurse to reduce the
risk of other limitations and promote the individual’s self-care capacities
(Table 24-1). Reassurance, support, and information can reduce barriers to
learning about and managing diabetes. The information in Box 24-2,
helpful in any patient education situation, offers guidance in teaching the
older diabetic patient.
TABLE 24-1 Nursing Problems Related to Diabetes Mellitus
BOX 24-2 General Guidelines for Patient
Education
ASSESS READINESS TO LEARN
Discomfort, anxiety, and depression may block learning and the
retention of knowledge. Relieving these symptoms, and allowing time
for patients to develop to the point where they desire and can cope with
information, may be necessary.
ASSESS LEARNING CAPACITIES AND LIMITATIONS
Consider the patient’s educational level, language problems, literacy,
present knowledge, willingness to learn, cultural background, and
previous experience with the illness, memory, vision, hearing, speech,
and mental status.
OUTLINE CONTENT OF PRESENTATION
Your outline should not only be specific and clear but also consider
learning priorities. Nurses sometimes feel obligated to teach every detail
about an illness, condensing a multitude of new facts and procedures into
a short time frame. Most people need time to receive, absorb, sort, and
translate new information into behavioral changes; older adults are no
different. Altered cerebral function or slower responses may further
interfere with learning in the aged. Patients and their families should
have a role in setting teaching priorities; the most vital information
should be given first, followed by other relevant material. Visiting nurses
and other resources should be used after hospital discharge to continue
the teaching plan if the proposed outline is not completed during the
hospitalization.
ALTER THE TEACHING PLAN IN VIEW OF
CAPACITIES AND LIMITATIONS
The nurse may feel that an explanation of the physiologic effects of
diabetes is significant for new diabetics. However, the older person who
tends to be confused or has a poor memory may not have long-range
benefit from this type of information. It may be better to use that time to
reinforce diet information or to make sure the most significant
information required for self-care is retained.
PREPARE THE PATIENT FOR THE TEACHING–
LEARNING SESSION
Patients should understand that education is an integral part of care.
Whenever possible, arrange a specific time in advance to avoid conflict
with other activities and to allow the family to be present if desired.
PROVIDE ENVIRONMENT CONDUCIVE TO
LEARNING
An area that is quiet, clean, relaxing, and free from odors and
interference will help create a good atmosphere for learning. Distraction
should be minimal, especially in view of the aged people’s reduced
capacity to manage multiple stimuli.
USE THE MOST EFFECTIVE INDIVIDUALIZED
EDUCATIONAL MATERIAL
It is important to recognize the limitations of standard teaching aids and
the importance of individualized methods. An aid that was successful for
one person may not be effective for another. The variety of sophisticated
audiovisual aids that are commercially prepared and available in many
agencies as resources for nurses are impressive, but they may not
necessarily be effective for the given patient. The quality of an audio
recording may be excellent, but it is of little benefit to the older person
with a hearing problem. A slide presentation, even slowly paced, may
present facts more rapidly than can be absorbed by an older person with
delayed response time. The print on a commercial pamphlet may appear
minute to older eyes. The language used in many commercial materials
may not be one to which the person is accustomed. Original handmade
aids suited for the individual's unique needs may have a value equal to or
greater than commercially prepared ones. Selectivity in methodology is
essential.
USE SEVERAL APPROACHES TO THE SAME BODY OF
KNOWLEDGE
The greater the number of different exposures to new material, the
higher the probability that the material will be learned. Combine verbal
explanation with charts, diagrams, pamphlets, demonstrations,
discussions with other patients, and audiovisual resources.
LEAVE MATERIAL WITH THE PATIENT FOR LATER
REVIEW
Often, it is helpful to summarize the teaching session in writing, using
language familiar to the patient. This provides concrete material that the
patient can review independently later and share with the family.
REINFORCE KEY POINTS
Reinforcement should be regular and consistent, with all staff members
supporting the teaching plan. For example, if the objective of the nurse
caring for the patient has been to increase competency in self-injection
of insulin, then the person substituting on the nurse’s day off should
comply with the established objectives rather than administering the
insulin for the individual. Informal reinforcement of information during
other daily activities should also be planned.
OBTAIN FEEDBACK
Evaluate whether the patient and family have received and understood
accurately the information communicated. An effective technique used
frequently in nursing and health care is the teach-back method. This
entails asking the patients to repeat back what was just instructed or what
they understood from the teaching session in their own words. This is
very helpful to the nurse to evaluate if learning occurred and if the
patient misunderstood or forgot pertinent information (Goeman et al.,
2016). Other ways to evaluate learning are observing return
demonstrations, asking questions, and listening to discussions among
patients.
REEVALUATE PERIODICALLY
To ascertain retention and effectiveness of the teaching sessions,
informally reevaluate at a later time. Remember that retention of
information may be especially difficult for the older individual.
DOCUMENT
Describe specifically what was taught, when, who was involved, what
methodology was used, the patient’s reaction and understanding, and
future plans for remaining learning needs. This assists the staff caring for
patients during their hospitalization and serves as a guide for those
providing continued care after discharge.
KEY CONCEPT
As diabetes impacts and is impacted by many facets of a person’s life,
patient education must be comprehensive and individualized.
Drug Therapy.
A variety of medications, including oral and injectable choices, may be
used to control hyperglycemia. Patient-centered care with goal setting for
HbA1c goal and blood sugar goals must be the focus of care, including
preferences, abilities, and living conditions to prevent adverse reactions and
promote successful outcomes. The avoidance of hypoglycemia is another
mainstay in geriatrics, especially with frail older adults (Leroith et al.,
2019). The first-line drug according to the ADA and several other
organizations is metformin, an oral antidiabetic agent for patients with Type
2 DM. Metformin has a low risk of hypoglycemia, which is very beneficial
in the older adult; however, it needs to be avoided when there is significant
renal disease with decreased glomerular filtration rates (GFR) 45 mL/min
or less. Other conditions that metformin should not be used to treat include
hepatic disease, alcoholism, severe congestive cardiac failure, severe
peripheral vascular disease, and severe chronic obstructive pulmonary
disease. Metformin has been shown to cause gastrointestinal adverse
reactions such as nausea, vomiting, diarrhea, and abdominal pain in 20% to
30% of patients, with older adults being more at risk to develop these. In
addition, 5% of patients are unable to continue treatment with metformin
due to severe symptoms (Dujic et al., 2015). Metformin should be
administered with meals to avoid gastrointestinal disturbances; starting with
a smaller dose can reduce this side effect, but frequently this is not effective
in treating the GI upset.
Sulfonylurea drugs—such as glipizide, glimepiride, glyburide (also
known as glibenclamide)—stimulate insulin secretion by blocking
adenosine triphosphate–sensitive potassium channels on pancreatic β cells.
However, the use of glyburide/glibenclamide in older persons carries a risk
of severe hypoglycemia, and this is believed to be related to delayed
clearance of the active metabolites of this drug. This is a particular risk in
patients with dementia; research has shown that sulfonylureas cause severe
hypoglycemia in patients with dementia and should be used with caution
(Abbatecola et al., 2015). Due to these risks, glipizide and gliclazide (no
longer available in the United States), which have shorter half-lives and few
or no active metabolites, are preferred sulfonylurea agents in older persons
with diabetes. The latest generation sulfonylurea, glimepiride, appears to be
more selective than the earlier agents and carries a lower risk for causing
vasoconstriction of small vessels; however, this drug and glyburide remain
on the Beers Criteria List to avoid due to prolonged hypoglycemia risk.
Besides exhibiting less hypoglycemia compared with
glyburide/glibenclamide, this drug appears to be more specific for islet cell
potassium channels and is less likely to produce coronary artery
vasoconstriction. Sulfonylurea medication should be taken a half-hour
before meals. It is recommended that the drug be started at a low dose,
about half of the usual adult dosage, and gradually increased if required.
Acarbose, an α-glucosidase inhibitor, reduces postprandial
hyperglycemia with lesser effect on fasting glucose levels and is safe for
older adults. Gastrointestinal disturbance, particularly flatulence, is the
major side effect of acarbose, which can be minimized by starting with a
smaller dose and gradually increasing the dosage if required. Repaglinide is
a short-acting insulinotropic antidiabetic agent that has similar effectiveness
and safety in older and younger adults. It acts principally by augmenting
endogenous insulin secretion from the pancreas in response to a meal. This
drug needs to be taken with meals.
Rosiglitazone and pioglitazone are thiazolidinediones that can be used
alone or in combination with sulfonylureas, metformin, or insulin for the
management of type 2 diabetes mellitus. They act principally by increasing
insulin sensitivity in target tissues, as well as decreasing hepatic
gluconeogenesis; they do this without stimulating insulin release from
pancreatic β cells, thereby reducing the risk of hypoglycemia. The reduced
risk of hypoglycemia makes them well suited for use in older adults.
Cardiac function must be assessed in all patients before starting these drugs
as they can precipitate cardiac failure in patients with cardiac dysfunction.
Caution is needed in patients with liver disease; liver enzymes should be
monitored closely for all patients using these drugs. There are multiple
antidiabetic medications on the market that have implications for the older
adult. Adherence to the drug plan is important for the nurse to assess and
communicate with the health care provider/team to identify problems and
simplify the treatment. (See Table 24-2.)
TABLE 24-2 Noninsulin Drugs for Diabetes Mellitus With

Implications for Older Adults (OA)
ADRs, adverse drug reaction; AKA, also known as; AKI, acute kidney injury; BC, Beers Criteria;
CV, cardiovascular; GI, gastrointestinal; HbA1c, glycosylated hemoglobin; UTI, urinary tract
infection.
Table compiled from research cited in Reuben et al. (2020) a; Medical Letter Drug and Therapeutics
(November 2019) b; Prescribers Letter (July 2019).c
Some individuals require only oral hypoglycemic agents to control their

diabetes. Those on insulin therapy who have lost weight or have not
experienced ketoacidosis alternate therapy with oral hypoglycemic agents
may be advised. Still others will need periodic changes in their insulin
dosages to meet changing demands. These factors, combined with other
management difficulties in the older diabetic person, necessitate frequent
reevaluation of the patient’s status. The continuation of health supervision is
an essential part of diabetic management.
KEY CONCEPT
Sliding scale insulin should not be used as a long-term means to manage
diabetes because it carries a high risk of hypoglycemia. It may be useful
for patients newly diagnosed with diabetes until their needs are
established. In these circumstances, the sliding scale orders should be
reevaluated within a week and patients closely observed. Basal–bolus
insulin regimens are those in which a basal (long-acting) insulin provides
control of blood glucose levels throughout the entire day and a bolus
rapid-acting insulin controls blood glucose levels following a meal.
Basal–bolus insulin regimens more closely resemble the body's natural
actions, allow flexibility in mealtimes, and reduce hypoglycemic events.
(See Table 24-3.)
TABLE 24-3 Insulin Preparations
Source: Reuben, D. B., Herr, K., Pacala, J. T., Pollock, B. G., Potter, J. F., & Semla, T. P. (2020).
Geriatrics at your fingertips (22nd ed.). New York, NY: American Geriatrics Society. Prescribers
Letter (November 2019).
Patient Self-Care and Monitoring.
If an older person with diabetes must self-inject insulin, there are several
factors that must be considered. Is the patient’s vision adequate and manual
dexterity of upper extremities adequate to handle a syringe and vial of
insulin? Another factor is the patient’s cognitive ability to understand and
follow safe injection technique with correct dose of insulin.
The use of insulin needs to be congruent with the patient’s cognition,
motor skills, function, and level of sensory system impairment (vision,
tactile sensation). The goals of glycemic control need to be individualized
with a focus on hypoglycemia prevention. It may not be appropriate to
expect a frail older adult or one with cognitive impairment to independently
administer multiple daily injections.
There is a debate regarding the insulin preparations that are optimum in
this population: the analog insulins versus the recombinant human insulin.
Does recombinant insulin cause more hypoglycemia? Is the cost of analogs
worth the benefit? Will analogs give better glycemic control? The cost of
the analogs is 2 to 2½ times more than the recombinant. Some experts feel
that the cost is not worth the benefit. The AGS (American Geriatric
Society) advises that the analogs are no more effective than recombinant
and can have a higher risk of hypoglycemia (Reuben et al., 2020). Luo et al.
(2019) reported in JAMA on a research study for Medicare beneficiaries in
which older adults with Type 2 DM who switched from analog insulin to
recombinant human insulin demonstrated a small benefit in HbA1c
decrease with analog insulins, but that the benefit is probably not clinically
significant without increase in hypoglycemia. However, many older adults
are taking analog insulins. The main point is to provide patient-centered
care. In older adults using insulin isophane (NPH) with night-time
hypoglycemia, it may necessary to contact the HCP for adjustment to
analog insulin (i.e., glargine) or to add a bedtime snack. Patients on regular
insulin with labile eating patterns maybe switched to analog insulin (e.g.,
lispro, aspart) or other by mouth medications by the medical team.
Several repeat demonstrations of injection technique should be
performed during the patient encounter in the hospital, office visit, or home
visit, especially on days when illness is acute (e.g., fatigue, neuropathic
pain, arthritis discomfort is present, etc.). Also, because most older persons
have some degree of visual impairment, the nurse must evaluate their
ability to read the calibrations on an insulin syringe. Some of the new
insulin pens that are available can assist older adults in delivering the
correct amount of insulin easily, but they are more costly.
All patients on insulin are at risk for hypoglycemia. Any patient
receiving insulin needs to be taught signs and symptoms of hypoglycemia
and treatment with 15 g of carbohydrates every 15 minutes, with blood
sugar checks until glucose stabilizes. Identification of the cause of
hypoglycemia is very important, particularly in older adults, due to the
morbidity and mortality associated with hypoglycemia. In hospital
situations, dextrose 50% is given intravenously in severe hypoglycemia
with or without cognitive impairment. In the community setting and nursing
home setting, quick-acting glucose preparations for by-mouth use need to
be available in addition to glucagon injectable. Regular insulin needs to be
given 30 minutes prior to the meal, which can be inconvenient because it is
necessary to wait to achieve optimum blood sugar lowering during the
meal. Also, if the patient receiving regular insulin does not eat the meal, the
risk of hypoglycemia will increase. NPH insulin also has risk of nocturnal
hypoglycemia, so basal insulin maybe a safer choice, especially for frail
older adults. Insulin preparations can be 100, 200, 300, or 500 units per mL,
so the nurse needs to be aware of the dilution ordered. There are many
premixed solutions with different combinations and concentrations of rapid
or short-acting insulin with intermediate insulin, which can be convenient
but difficult to adjust doses. Risk of hypoglycemia is again present when
using these combinations. (See Table 24-3.)
The older individual can be hyperglycemic without being glycosuric.
Higher blood glucose levels are common in older adults, and minimal or
mild glycosuria is usually not treated with insulin. Although nurses are not
responsible for prescribing insulin coverage, they need to be aware that the
insulin requirements of older patients are individualized. Responses to
various insulin levels should be carefully observed and communicated to
the physician.
Many diabetic patients must perform blood glucose level testing using a
finger-prick method. Patients must be instructed in this technique and must
demonstrate competence in performing it. Patients on long-acting and
short/rapid-acting insulin require blood glucose monitoring frequently,
premeals, and at bedtime, in addition to postprandial checks periodically.
Type 2 diabetic patients who are on noninsulin medication do not need to
check their blood sugar this frequently. Another option is continuous
glucose monitoring (CGM), which uses a small needle in the subcutaneous
skin attached to a sensor that can assess glucose levels continuously. CGM
is used in type 1 patients but may be useful in type 2 patients on insulin
with hypoglycemia episodes. An infrared device and other noninvasive to
minimally invasive devices to monitor glucose levels have been researched
intensively with the hope that they will be available in the near future. The
infrared device determines the blood glucose level by measuring how light
is absorbed by the body. The patient sticks a finger into a small meter that
shines an infrared light through the skin. The infrared method should make
glucose testing more convenient and pain free for diabetic persons.
The hemoglobin A1c test (also called HbA1c, glycated hemoglobin test,
or glycohemoglobin) measures the amount of glycosylated hemoglobin in
the blood and is used to monitor the effectiveness of disease control.
Glycosylated hemoglobin is a molecule in red blood cells that attaches to
glucose. Hemoglobin A1c provides an average of the patient’s blood
glucose control over a 6- to 12-week period; the normal range is between
4% and 6%. For adults with diabetes, the goal is HbA1c below 7%. This
test is usually performed quarterly.
A consensus report was developed by the American Diabetes
Association (ADA) and American Geriatric Society (AGS) for glycemic
and blood pressure goals including the use of statins in the older adult
(Kirkman et al., 2012). This was a major accomplishment and shift in
management of diabetes with the older population and remains relevant
today; it is even included in the recent global endocrine society clinical
guidelines (Leroith et al., 2019). It focuses on function and the existence of
comorbid conditions with or without complex illnesses and cognitive
impairment. Rather than chronological age, the focus is on function,
cognition, risk, and benefit of treatment and hypoglycemic concerns. The
report designates three distinct categories of older adults (Blaum et al.,
2010): (1) patients who are healthy; (2) patients with a few complex
medical illnesses and some functional deficits; and (3) patients with very
complex medical conditions and significant functional impairment. The
major categories that the consensus report addresses are geriatric syndromes
such as cognitive changes, functional impairment, increased falls and
fracture risk in diabetes, polypharmacy, depression, and sensory impairment
(vision and hearing), along with commonly occurring medical conditions.
These conditions impact the goals for fasting glucose levels, the HbA1c
goal, an acceptable blood pressure, and the use of statins. It is
recommended that healthy older adults—with few coexisting chronic
illnesses, intact cognition, and optimum functional status without ADL
impairment—achieve a HbA1c goal of less than 7.5% ADA (2020) instead
of less than 6.5% or 7.0%, according to the diabetic experts’ usual
recommendations for adults. However, less than 7.0% HbA1c may be
appropriate for healthy older adults with extended life expectancy (i.e.,
persons in their late 60s). The consensus report details the specific goals for
patients with multiple moderate to complex illnesses, cognitive deficits, and
impairment in ADLs. Patients with severe impairment and complex medical
illnesses can achieve an HbA1c goal of less than 8.5%, which would be
considered acceptable. (See Table 1 of Kirkman et al., 2012, titled
Framework for Considering Treatment Goals for Glycemia, Blood pressure,
and Dyslipidemia in Older Adults With Diabetes.)
Triglyceride monitoring is also important. People with diabetes are at
risk for metabolic syndrome , characterized by the combination of high
triglycerides, low high-density lipoprotein, and central obesity. The risk of
premature death from cardiovascular disease is increased in persons with
these factors. The American Diabetes Association recommends that people
with diabetes maintain their triglyceride levels below 150 mg/dL.
COMMUNICATION TIP
It is useful to periodically review the way patients who have had
diabetes for a long time are managing the care of their disease.
Individuals may have made changes to their diets or medication
administration routines without advising their health care provider. In
addition, they may be experiencing physical, emotional, or cognitive
issues that interfere with their compliance with the recommended
plan. Rather than presenting questions requiring yes/no responses
(e.g., Are you still giving yourself your insulin? Are you sticking to
your diet?), asking instead for them to describe their routine care and
medication administration practices can aid in identifying factors that
could affect their care and well-being.
Exercise and Nutrition.

Regular exercise is important for older diabetic patients and provides
multiple health benefits, including improved glucose tolerance, increased
muscle strength, decreased body fat, improved maximal oxygen
consumption, and improved lipid profile (Fig. 24-1). Physical activity can
improve the patient’s response to insulin during the period in which the
exercise regimen is done if the exercise is sufficient to lower the resting
heart rate. In the diabetic individual, however, a vigorous exercise program
or changes in an exercise program must be reviewed with the physician to
prevent adverse consequences. For example, moderate to vigorous exercise
increases the absorption of insulin and heightens the use of glucose by the
exercising muscles, potentially leading to hypoglycemia.
FIGURE 24-1 Regular exercise provides multiple health
benefits for older diabetic patients.
Attempts should be made to maintain a consistent daily food intake

because an insulin dosage is prescribed to cover a specific amount of food.
This may be difficult if the older person has a minimal food intake during
the week when alone but an increased intake when visiting with family on
weekends or if the patient skimps on meals when financial resources are
low. Older people may also be limited in their ability to purchase and
prepare adequate meals because of financial, energy, or social limitations.
This can interfere with management of the illness. Meals on wheels, food
stamps, the assistance of a neighbor, and other appropriate resources should
be used to assist the individual. Psychosocial factors can influence
consistent food intake as much as physical factors. The nurse and physician
must carefully assess, plan, and manage insulin needs in view of the
individual’s unique problems and lifestyle. Older adults in a hospital or
nursing home setting require special attention to ensure that food intake is
regular and adequate.
KEY CONCEPT
Psychosocial factors can alter food intake from day to day and affect
insulin requirements.
A diet high in complex carbohydrates and fibers controls the release of

glucose into the bloodstream and can reduce insulin requirements.
Nutritional supplements can reduce the risk of complications; such
supplements include vitamin B6, folic acid, riboflavin (B2), magnesium,
zinc, and chromium. Herbs with hypoglycemic properties include bilberry,
fenugreek, garlic, ginseng, and mulberry leaves.
POINT TO PONDER
Consider your schedule of eating, exercise, sleep, and rest. How
consistent a pattern do you have from day to day, and what adjustments
would you need to make if you had to live with a condition such as
diabetes?
Complications
Older people are subject to a long list of complications from diabetes and
have a greater risk of developing these complications than younger adults.
Hypoglycemia seems to be a greater threat to older patients than
ketoacidosis, and this is especially problematic because of the possible
presentation of a different set of symptoms. Classic symptoms such as
tachycardia, restlessness, perspiration, and anxiety may be totally absent in
the older individual with hypoglycemia. Instead, any of the following may
be the first indication of the problem: behavior disorders, convulsions,
somnolence, confusion, disorientation, poor sleep patterns, nocturnal
headache, slurred speech, and unconsciousness. Uncorrected hypoglycemia
can cause tachycardia, arrhythmias, myocardial infarctions, cerebrovascular
accident, and death.
KEY CONCEPT
Rather than the classic symptoms of hypoglycemia that one would
anticipate in younger adults, older individuals instead may experience
confusion, abnormal behavior, altered sleep patterns, nocturnal
headache, and slurred speech.
Peripheral vascular disease is a common complication in the older

individual who has diabetes and is influenced by the poorer circulation and
atherosclerosis often associated with increased age and disease
complication with micro- and macrovascular damage. Symptoms may range
from numbness and weak pulses to infection and gangrene. The nurse
should identify and promptly communicate to the physician the symptoms
of peripheral vascular disease. Educating the patient in proper foot care and
in the early detection of foot problems can help reduce the risk of this
problem; referral to a podiatrist also can prove beneficial. (See Chapter 21
for a discussion of foot care.)
CONSIDER THIS CASE
Mr. Clarkson, a 75-year-old widower who

lives alone, is visiting the primary care center for his regular 6-month
checkup. Last year, he was diagnosed with diabetes that was to be
managed through diet and an oral hypoglycemic agent. Today, he is found
to have an elevated blood glucose level and has signs of dehydration.
When asked about symptoms, he admits that he has “felt sluggish lately.”
When questioned, Mr. Clarkson confirms that he is taking his
medication as prescribed; however, when he shows the nurse his
prescription bottle, the nurse notices that the 90-day supply of medications
was obtained over 4 months ago. When questioned about his diet, Mr.
Clarkson seems evasive and comments, “I’ve never been a great cook, but
I get by.”
THINK CRITICALLY
1. What factors could be contributing to Mr. Clarkson’s
symptoms?
2. What type of questions could be posed to Mr. Clarkson to learn
more about the factors contributing to his status?
3. What resources could aid Mr. Clarkson in addressing the

various factors that could be interfering with his management of
his diabetes?
Another significant vascular problem of older patients with diabetes is

retinopathy with consequent blindness. Individuals who are hypertensive or
who have had diabetes for a long time have a greater risk of developing this
complication. Hemorrhage, pigment disturbances, edema, and visual
disorders are manifested with this problem.
Many older patients taking sulfonylureas experience hypoglycemia.
There are many age-related factors that increase the risk of hypoglycemia,
including the age-related changes in hepatic and renal functions that alter
drug metabolism and excretion. Aging is also associated with impairments
in the autonomic nervous system and reductions in adrenergic receptor
function, suggesting decreased response to hypoglycemia in older adults.
This can be dangerous as older people may not display warning symptoms
such as tremors, sweating, and palpitation; before it is recognized, their
hypoglycemia can progress to convulsions or coma and death.
Drug interactions can be a major source of complications for older
diabetic patients. Older adults are frequent users of drugs that are known to
increase the risk of hypoglycemia, including β-blockers, salicylates,
warfarin, sulfonamides, tricyclic antidepressants, and alcohol. Nurses
should review all medications the patient is taking to identify those drugs
that may interact with antidiabetic medications. Nurses also must consider
asking about the use of herbal remedies that could affect blood glucose
levels.
A variety of additional complications can affect older individuals who
are living with diabetes. Cognitive impairment can be a complication.
Studies have found that diabetes is a factor in aging the brain an average of
5 years beyond the normal effects of aging and causing cognitive decline
beyond what would be expected for older adults (Rawlings et al., 2014).
Older persons may develop neuropathies, demonstrated through tingling
sensations progressing to stinging or stabbing pain, carpal tunnel syndrome,
paresthesias, nocturnal diarrhea, tachycardia, and postural hypotension.
They have twice the mortality rate from coronary artery disease and
cerebral arteriosclerosis and a higher incidence of urinary tract infections.
They also have a higher risk of problems developing in virtually every body
system. Early detection of complications is essential and can be facilitated
by nursing intervention and patient education. Competent management of
the older patient with diabetes is a vital activity that requires considerable
skill and poses a great challenge and responsibility to the practice of
nursing. The recognition of differences in symptomatology, diagnosis,
management, and complications is crucial. Box 24-3 lists some potential
care plan goals. Resources of benefit to patients with diabetes are listed at
the end of this chapter.
BOX 24-3 Care Plan Goals for the Patient With

Diabetes
To verbalize understanding of diabetes and its management
To demonstrate proper technique for administration of antidiabetic
medication
To demonstrate correct method of blood glucose testing
To be free from signs of hypoglycemia and hyperglycemia
To describe signs and symptoms of hypoglycemia and insulin shock
To adapt management of diabetes to lifestyle
To maintain weight at appropriate level or to lose specified amount
To engage in a regular exercise program
To be free from injury
To be free from infection
To be free from impairments in skin integrity
To be free from complications associated with diabetes
To be able to manage/cope with the disease to enjoy a quality of life
Hypothyroidism
Thyroxine (T4) and triiodothyronine (T3) are essential hormones produced
by the thyroid gland. Aging affects the thyroid gland in several ways,
including moderate atrophy, fibrosis, increasing colloid nodules, and some
lymphocytic infiltration. Although production of T4 declines with age, this
is believed to be a compensatory process related to decreased tissue use of
the hor mone; serum levels of thyroid hormones do not significantly
change.
A subnormal concentration of thyroid hormone in the tissues is known
as hypothyroidism. This condition increases in prevalence with age and is
more common in women than in men. Hypothyroidism can be either
primary, resulting from a disease process that destroys the thyroid gland, or
secondary, caused by insufficient pituitary secretion of thyroid-stimulating
hormone (TSH). Primary hypothyroidism is characterized by low free T4 or
free T4 index with an elevated TSH level; secondary hypothyroidism
displays low free T4 or free T4 index and low TSH. A subclinical
hypothyroidism can exist in which the person is asymptomatic but has an
elevated TSH level and normal T4. If symptoms are present but TSH, T3,
and T4 levels are normal, checking the thyrotropin-releasing hormone
(TRH) level may benefit the patient; the TRH level is more sensitive than
the other thyroid levels and could help reveal subnormal thyroid function.
Symptoms
Symptoms of hypothyroidism can be easily missed or attributed to other
conditions and include the following:
Fatigue, weakness, and lethargy

Depression and disinterest in activities
Anorexia
Weight gain and puffy face
Impaired hearing
Periorbital or peripheral edema
Constipation
Cold intolerance
Myalgia, paresthesia, and ataxia
Dry skin and coarse hair
Treatment
Treatment includes replacement of thyroid hormone using a synthetic
thyroxine (T4), levothyroxine. Initially, a low dose is recommended to
avoid exacerbation of asymptomatic coronary artery disease that could
occur from rapid replacement. Levothyroxine is the drug of choice for
maintenance therapy in hypothyroidism. The drug needs to be given on an
empty stomach, first medication in the morning, 1 hour prior to other
medications or food. The half-life is long, about 6 to 7 days; therefore,
rechecking the TSH level in 6 weeks of dose adjustment will reflect steady
state and effectiveness of current dose (Reuben et al., 2020). The nurse
needs to be aware of correct medication administration and educate patients
and families in administration and the delay of several weeks to months to
achieve euthyroid state and alleviate symptoms. Regular monitoring
provides feedback for the need for dosage adjustments. Levothyroxine and
l-triiodothyronine (T3) combinations and thyroid USP are not
recommended (Reuben et al., 2020). Also, the endocrine society and AGS
do not recommend treatment of subclinical hypothyroidism without
symptoms with TSH levels 5 to 10 mIU/L with low to normal free
thyroxine (T4) due to no evidence of improvement in clinical conditions.
The research also demonstrated improved outcome in untreated
symptomatic subclinical hypothyroid with reduced morbidity and mortality
(Cappola et al., 2015; Reuben et al., 2020).
KEY CONCEPT
Initially, thyroid replacement is prescribed at a low dose and gradually
increased under close supervision to prevent cardiac complications.
Nursing measures should support the treatment plan and assist patients
with the management of symptoms (e.g., prevention of constipation and
provision of extra clothing to compensate for cold intolerance). It is
important that patients understand that thyroid replacement will most likely
be a lifelong requirement.
Hyperthyroidism
At the other extreme from hypothyroidism is a condition known as
hyperthyroidism. In this disorder, the thyroid gland secretes excess amounts
of thyroid hormones. Hyperthyroidism is less prevalent than
hypothyroidism in older adults; it affects women more than men. A
potential cause of hyperthyroidism in older patients that should be
considered is related to the use of amiodarone, a cardiac drug containing
iodine that deposits in tissue and delivers iodine to the circulation over very
long periods of time. Amiodarone-induced thyroid dysfunction is prevalent;
initial screening and periodic monitoring should be done with patients on
amiodarone to evaluate its impact on thyroid function
Diagnostic testing can be challenging because blood tests do not always
reflect hyperthyroidism. This is particularly true in malnourished older
people, whose T3 levels are reduced due to their nutritional status; thus, the
excess secretion will cause the T3 to fall within a normal range. Diagnosis
relies on evaluation of T4 and free T4, TSH, and increased uptake of
radionuclide thyroid scans.
Symptoms
Classic symptoms of hyperthyroidism include diaphoresis, tachycardia,
palpitations, hypertension, tremor, diarrhea, stare, lid lag, insomnia,
nervousness, confusion, heat intolerance, increased hunger, proximal
muscle weakness, and hyperreflexia. However, as with hypothyroidism,
hyperthyroidism can present with atypical symptoms in older adults. For
example, increased perspiration may not occur, and for the person with a
history of chronic constipation, diarrhea may be displayed by now having
regular bowel movements.
Treatment
Treatment of hyperthyroidism depends on the cause. In Graves’ disease, an
autoimmune disorder that leads to the production of an antibody to the TSH
receptor that stimulates thyroid growth and overproduction of thyroid
hormone, or when there is a single autonomous nodule, treatment typically
includes antithyroid medications or radioactive iodine. If toxic multinodular
goiter is the underlying cause, surgery may be preferred due to the delayed
and incomplete response to medications. Hypothyroidism can develop as a
complication in persons who have had surgery or radioactive iodine therapy
and may require thyroid replacement medication.
Medications can be used to conservatively manage hyperthyroidism and
symptoms. Methimazole is the first-line drug choice with TSH monitoring
to determine effectiveness. If the patient has an allergy or intolerance to
methimazole, propylthiouracil is second-line choice. Due to the risk of
serious liver injury, propylthiouracil should only be used in failed
methimazole therapy or when such therapy is contraindicated.
Patients with a history of thyroid disease need special monitoring when
experiencing an acute illness, surgery, or trauma because this can precipitate
extreme thyrotoxicosis (thyroid storm). Hospitalization may be required to
return their thyroid level to a normal range.
The Symptom Experience of Older Adults With

Type 2 Diabetes and Diabetes-Related Distress
Source: Lenore, H., Leutwyler, H., Cataldo, J., Kanaya, A., & Swislocki, A.
(2019). Nursing Research, 68(5), 374–382.
The number of persons with diabetes in the general population, as well
as the number of older adults with diabetes, is increasing and will continue
to do so over the next few decades. Older adults with diabetes are at risk for
poorer outcomes with increased mortality, functional impairment, and
institutionalization. This article looked at the emotional response to stress-
related disease burden, such as worry, frustration, and burnout. Other issues
investigated were stress related in obtaining proper treatment and
communicating with health care providers. These emotional reactions to the
stress of the disease and risk of a life-changing illness are predictable. It has
been discussed in the literature that up to 40% of all persons diagnosed with
diabetes experience distress related to the disease. The daily requirements
of the illness on physical and psychological status can be demanding and
draining. Depression has been identified as a frequent comorbid condition
associated with diabetes. Although depression assessments have been
utilized with persons with diabetes, such assessments may be missing the
distress of the illness causing an emotional reaction. It would be beneficial
to assess not only depression but also the distress. Persons with diabetes
experiencing distress may be less likely to take their prescribed
medications. The research literature has shown that distress is a barrier to
adequate blood glucose control, which increases complication risk. This
study’s goal was to identify symptoms and diabetes-related distress specific
to the older adult and find treatment approaches to successfully help the
older adult independently manage the disease. The research focused on the
lived experience of the older adult with diabetes utilizing interpretive
interviews. These interviews addressed the daily health and life experience
related to being an older adult with diabetes.
The conditions identified in symptom burden were fatigue,
hypoglycemia, diarrhea, pain, loss of balance, and falling. The distress that
was identified by the participants led to their significant loss of
independence, poor quality of life, and social isolation. This research
illuminated the need of the health care team to identify symptom burden
and distress to assess and intervene on important issues impacting the
person with diabetes. As part of the health care team, nurses can identify
inactivity and fall risks to develop plans to address mobilization,
strengthening, and balance exercises to reduce fall risk and improve quality.
Fatigue can be addressed by evaluating sleep hygiene, hyperglycemia,
inactivity, polypharmacy, and managing the causes with the health care
team. The diarrhea experience affected the quality of life and increased
social isolation behaviors. Neuropathic changes in the GI system can cause
diarrhea; however, several of the participants associated the diarrhea with
metformin and self-adjusted the dose without contacting the prescriber. This
is an opportunity for the nurse to assess for diarrhea, especially when the
older adult is taking metformin, to educate the patient and communicate
with the prescriber the side effects experienced. When assessing for pain,
the nurse can directly impact the older adult with addressing
nonpharmacological interventions, in addition to working with health care
providers to develop an effective pain treatment plan.
The symptom experience and distress are important components for
nurses to identify with each individual older adult. Nurses can have an
integral role in assisting the older adult with diabetes to identify symptom
burden and the resultant distress to intervene for better outcomes in their
life and diabetic control. This was a small sample size (N = 16), but the
focus and content are important and hopefully can fuel further research into
symptom burden and illness distress, with clinical interventions to assist the
older adult with diabetes and improve outcomes and the lived experience.
PRACTICE REALITIES
Eighty-three-year-old Mr. Vincent has been diagnosed with diabetes
mellitus. At 5′ 7″ and 290 lb, his excess weight is contributing to his
problem. He and his wife, who is also obese, have been counseled and
educated on the need to reduce weight and to follow good dietary practices.
At his first follow-up visit, Mr. Vincent is found to have gained 4 lb.
When questioned, he admits to not following his dietary plan and instead
eating the heavy pastas, fried foods, and cakes that his wife continues to
prepare. “She’s a great cook and I love the dishes she makes,” he said.
Mrs. Vincent who accompanies him on the visit adds, “He’s been so
worried about his diabetes and these little treats help to calm him. After all,
at our age good eating is one of the few pleasures we have.”
The record indicates that Mr. Vincent has been advised that he has
circulatory and visual problems that are most likely related to his diabetes,
so he has been informed of the risks associated with noncompliance.
How do you balance Mr. Vincent’s lifelong eating habits and desires
against the risks he is subjecting himself to? What actions could you take?

1. Discuss reasons for different norms to be used to interpret the
outcomes of glucose tolerance tests in older adults.
2. Describe the challenges to physical and psychosocial well-being

faced by the older diabetic patient.
3. In what ways do age-related changes affect the presentation of

symptoms and risks associated with diabetes and thyroid disease?
4. Outline a teaching plan for the person with hyperlipidemia that

includes natural and alternative/complementary therapies.

questions.
Mr. Angelo, a 75-year-old widower who lives alone, is visiting the

primary care center for his regular 6-month checkup.
Nurse’s
Notes
1100: Last year, Mr. Angelo was diagnosed with diabetes that was to be
managed through diet and an oral hypoglycemic agent. Today, he is
found to have an elevated blood glucose level and has signs of
dehydration. When asked about symptoms, he admits that he has “felt
sluggish lately.”
When questioned, Mr. Angelo confirms that he is taking his
medication as prescribed; however, when he shows the nurse his
prescription bottle, the nurse notices that it contains a substantial amount
of the 90-day supply of medications that was obtained over 4 months
ago. When questioned about his diet, the client seems evasive,
commenting, “I’ve never been a great cook, but I get by.”
Chapter Summary
Changes that occur to the endocrine system with age include reductions in
thyroid gland activity, radioactive iodine uptake, secretion and release of
thyrotropin, pituitary gland volume, pancreatic release of insulin, and
adrenocorticotropic hormone secretion. These changes ultimately reduce
the secretion of estrogen, progesterone, androgen, 17-ketosteroids, and
glucocorticoids.
Type 2 diabetes affects 20% of the older population and can be difficult
to diagnose in an early stage due to the absence of classic symptoms. Some
indications of diabetes in older adults include orthostatic hypotension,
periodontal disease, stroke, gastric hypotony, impotence, neuropathy,
confusion, glaucoma, Dupuytren’s contracture, and infection. Because the
renal threshold for glucose increases with age, older individuals can be
hyperglycemic without evidence of glycosuria, thus limiting the validity of
urine testing for glucose. Several glucose tolerance tests are recommended
for effective diagnosis of the disease. Careful management is important
because older individuals are at high risk of developing complications, such
as hypoglycemia, peripheral vascular disease, retinopathy, cognitive
impairment, and drug interactions. Because diabetes can significantly
impact the patient’s life and have serious consequences, comprehensive and
individualized care and education are essential.
Hypothyroidism increases in prevalence with age. The symptoms can
easily be missed or confused with other conditions. Treatment consists of
replacement therapy with a synthetic thyroid drug, initially prescribed at a
low dose and gradually increased.
Hyperthyroidism is less prevalent than hypothyroidism in older adults.
Typical symptoms may not appear, and diagnosis can be challenging,
relying on evaluation of T4 and free T4, TSH, and increased uptake of
radionuclide thyroid scans. Treatment will depend on the cause. Special
monitoring is crucial when persons with thyroid disease experience trauma,
surgery, or an acute illness because this can cause extreme thyrotoxicosis.
Online Resources
American Diabetes Association
http://www.diabetes.org
American Heart Association
http://www.americanheart.org
National Diabetes Education Program
http://www.ndep.nih.gov
National Diabetes Information Clearinghouse
http://www.diabetes.niddk.nih.gov
References
Abbatecola, A. M., Bo, M., Barbagallo, M., Incalzi, R. A., Pilotto, A., Bellelli, G., … on behalf of
the Italian Society of Gerontology and Geriatrics (SIGG), Florence, Italy. (2015). Severe
hypoglycemia is associated with antidiabetic oral treatment compared with insulin analogs in
nursing home patients with type 2 diabetes and dementia: Results from the DIMORA study.
Journal of the American Medical Directors Association, 16, 349.e7–349.e12.
Administration for Community Living. (2017). Profile of African Americans age 65 and over: 2017 .
Washington, DC: U.S. Department of Health and Human Services. Retrieved from
https://acl.gov/sites/default/files/Aging%20and%20Disability%20in%20America/2017OAProfil
eAfAm508.pdf
American Diabetes Association. (2020). 12. Older adults: Standards of medical care in diabetes—
2020. Diabetes Care , 43 (Suppl. 1), S139–S147. doi: 10.2337/dc20-s012.
Blaum, C. S., Cigolle, C. T., Boyd, C., Wolff, J. L., Tian, Z., Langa, K. M., & Weir, D. R. (2010).
Clinical complexity in middle-aged and older adults with diabetes: The health and retirement
study. Medical Care , 48 , 327–334.
Cappola, R., Arnold, A. M., Wulczyn, K., Carlson, M., Robbins, J., & Psaty, B. M. (2015). Thyroid
function in the euthyroid range and adverse outcomes in older adults. The Journal of Clinical
Endocrinology & Metabolism , 100 (3), 1088–1096. doi: 10.1210/jc.2014-3586.
Centers for Disease Control and Prevention. (2020). National diabetes statistics report: Estimates of
diabetes and its burden in the United States . Atlanta, GA: US Department of Health and
Human Services . Retrieved from https://www.cdc.gov/diabetes/pdfs/data/statistics/national-
diabetes-statistics-report.pdf
Clinical Resource, Comparison of Insulins. Pharmacist’s Letter/Prescriber’s Letter , 2019.
Clinical Resource, Drugs for Type 2 Diabetes. Pharmacist’s Letter/Prescriber’s Letter, 2019 .
Drugs for Type 2 Diabetes. (2019). Medical Letter Drugs and Therapeutics , 61 (1584), 169–178.
Dujic, T., Causevic, A., Bego, T., Malenica, M., Velija-Asimi, Z., Pearson, E. R., & Semiz, S. (2015).
Organic cation transporter 1 variants and gastrointestinal side effects of metformin in patients
with Type 2 diabetes. Diabetic Medicine , 33 (4), 511–514. doi: 10.1111/dme.13040.
Farhan, H., Albulushi, A., Taqi, A., Al-Hashim, A., Al-Saidi, K., Al-Rasadi, K., … Al-Zakwani, I.
(2013). Incidence and pattern of thyroid dysfunction in patients on chronic amiodarone therapy:
Experience at a Tertiary Care Centre in Oman. Open Cardiovascular Medicine Journal, 7, 122–
126.
Goeman, D., Conway, S., Norman, R., Morley, J., Weerasuriya, R., Osborne, R. H., & Beauchamp,
A. (2016). Optimising health literacy and access of service provision to community dwelling
older people with diabetes receiving home nursing support. Journal of Diabetes Research , 2016
, 1–12. doi: 10.1155/2016/2483263.
Heron, M. (2019). Deaths: Leading causes for 2017. National Vital Statistics Report , 68 (6), 1–77.
Kirkman, M. S., Briscoe, V. J., Clark, N., Florez, H., Haas, L., Halter, J. B., … Swift, C. S. (2012).
Diabetes in older adults: A consensus report. Journal of American Geriatric Society , 60 (12,
special), 2342–2356. Retrieved from www.ncbi.nlm.nih.gov/pmc/articles/PMC4525769/
Leroith, D., Biessels, G. J., Braithwaite, S. S., Casanueva, F. F., Draznin, B., Halter, J. B., … Sinclair,
A. J. (2019). Treatment of diabetes in older adults: An endocrine society clinical practice
guideline. The Journal of Clinical Endocrinology & Metabolism , 104 (5), 1520–1574. doi:
10.1210/jc.2019-00198.
Luo, J., Khan, N. F., Manetti, T., Rose, J., Kaloghlian, A., Gadhe, B., … Kesselheim, A. S. (2019).
Implementation of a health plan program for switching from analogue to human insulin and
glycemic control among medicare beneficiaries with Type 2 diabetes. JAMA , 321 (4), 374–384.
doi: 10.1001/jama.2018.21364.
Reuben, D. B., Herr, K., Pacala, J. T., Pollock, B. G., Potter, J. F., & Semla, T. P. (2020). Geriatrics
at your fingertips (22nd ed.). New York, NY: American Geriatrics Society.
Smalls, B. L., Ritchwood, T. D., Bishu, K. G., & Egede, L. E. (2020). Racial/Ethnic differences in
glycemic control in older adults with type 2 Diabetes: United States 2003–2014. International
Journal of Environmental Research and Public Health , 17 (3), 950. doi:
10.3390/ijerph17030950.
readings and other additional resources associated with this chapter.
CHAPTER 25
Skin Health
Chapter Outline
Effects of Aging on the Skin
Promotion of Skin Health
Selected Skin Conditions
Pruritus
Keratosis
Skin Cancer
Vascular Lesions
Pressure Injury
General Nursing Considerations for Skin Conditions
Promoting Normalcy
LEARNING OBJECTIVES
1. Summarize the effects of aging on the skin.

2. List practices that promote good skin health in older adults.
3. Describe signs of and nursing care for pruritus, keratosis, seborrheic
keratosis, skin cancer, stasis dermatitis, and pressure injury in older
adults.
4. Discuss measures that help older patients cope with skin problems and
feel normal.
5. Identify alternative therapies that promote good skin health in older
adults.
TERMS TO KNOW
Epidermisouter layer of the skin
Keratosissmall, light-colored benign lesions on epidermis
Melanocytesepidermal cells that give skin its color
Mongolian spotsirregular, dark areas (resembling bruises) that may be
found on the buttocks, lower back, and to a lesser extent on the arms,
abdomen, and thighs; more prevalent in persons of African, Asian, or
Native American backgrounds
Photoaging (solar elastosis)skin changes resulting from exposure to
ultraviolet rays
Pressure injurylocalized damage to skin and/or underlying soft tissue
resulting from pressure or pressure combined with shear or friction
Pruritusitching
Turgorelasticity
Perhaps, the most obvious effects of growing old are the changes involving
the skin. In addition to the effects of aging, past health practices largely
influence the status of the skin in late life; its status in late life, in turn,
influences older persons’ general health. In other words, problems
involving other body systems can result from unhealthy skin. Because
gerontological nurses often have more direct contact with older adults than
the other health care professionals, they play an important role in promoting
healthy skin and identifying signs of problems.
EFFECTS OF AGING ON THE SKIN

Lines and wrinkles, thicker nails, and graying hair are constant reminders of
the aging process. These result from common aging changes to the
integumentary system that include flattening of the dermal–epidermal
junction, reduced thickness and vascularity of the dermis, decreased rate of
epidermal turnover, degeneration of elastic fibers, increased coarseness of
collagen, and reduction in melanocytes . The increased fragility of the skin
poses challenges to older adults and their caregivers in that there are
heightened risks for skin tears, bruising, pressure injury, and skin infections.
In addition, the effects of this system’s aging on appearance are highly
visible signs of the aging process, potentially affecting body image, self-
concept, reactions from others, socialization, and other psychosocial
factors.
PROMOTION OF SKIN HEALTH

Some general measures can help prevent and manage dermatologic
problems in older persons. It is important to avoid drying agents, rough
clothing, highly starched linens, and other items irritating to the skin. Good
skin nutrition and hydration can be promoted by activity, bath oils, lotions,
and massages. Although skin cleanliness is important, excessive bathing
may be hazardous to the skin; unless there is a reason requiring bathing
more frequently, daily partial sponge baths and complete baths or showers
every 2 or 3 days are sufficient for the average older person. Early attention
to and treatment of pruritus and skin lesions are advisable for preventing
irritation, infection, and other problems.
In addition to increasing the risk of skin cancer, exposure to ultraviolet
rays damages the skin, causing a condition known as solar elastosis , or
photoaging . Loss of elasticity and wrinkling of the skin characterize this
sun-induced premature aging of the skin. Fair-skinned individuals who
easily burn when in the sun are at particularly high risk for this condition.
The skin changes associated with exposure to ultraviolet radiation may not
be apparent for years; therefore, sunbathing practices in youth affect the
skin condition in late life. Sun-screening lotions are beneficial in protecting
the skin; the sun protection factor (SPF) required will depend on the ease
with which the skin burns and could range from an SPF of 15 or more in
highly sensitive persons to an SPF of 4 to 6 in people who seldom burn and
tan dark brown easily. It should be applied to the entire face and body 15
minutes before going outside and reapplied at least every 2 hours (Food and
Drug Administration, 2019). Nurses can remind patients that skin damage
can occur on overcast days because ultraviolet rays can penetrate clouds.
With the increased prevalence of skin cancer in late life, educating older
adults in skin inspection for abnormalities is a beneficial action. Nurses
should encourage older adults to examine their entire bodies with special
attention to moles that could indicate possible carcinomas. To help them
remember signs to bring to their health providers’ attention, nurses can
instruct older adults in the A, B, C, and Ds for detecting unhealthy moles:
A—Asymmetry: If a mole is not round or symmetrical, or one half of

the mole is not similar to the other half, it could be a sign of
melanoma.
B—Border Irregularity: Cancerous moles have irregular borders that
may be uneven, ragged, notched, or blurred.
C—Color: The typical color of a mole is consistently brown
throughout. A mole that has changed color over time or is varied in a
shade of brown, tan, and black may be cancerous. If melanoma has
progressed, the mole may become red, blue, or white.
D—Diameter: Cancerous moles can be more than 6 mm in diameter
(about ¼ in. or the size of a pencil eraser).
Other mole variations that may indicate melanoma include elevation in

height from the skin surface both horizontally or vertically; a change in
feeling, such as itchiness, tenderness, or pain; and the tendency to bleed if
scratched. Knowing these signs can enable older individuals in being
proactive in their health care and obtaining evaluations and treatment while
problems are in an early stage.

Moles with edges that are uneven, ragged, notched, or blurred are possible
carcinomas. Cancerous moles can be the size of a pencil eraser, about 6
mm or ¼ in. in diameter.
Although less serious than the possibility of skin cancer, integument

issues affecting the appearance are another area for health promotion. All
individuals should be encouraged to look their best and make the most of
their appearance. However, efforts to avoid the normal outcomes of the
aging process can be fruitless and frustrating. Money that could be applied
to more basic needs is sometimes invested in attempts to defy reality. The
nurse should emphasize to persons young and old that no cream, lotion, or
miracle drug will remove wrinkles and lines or return youthful skin. While
clarifying misconceptions regarding rejuvenating products, the nurse can
encourage the use of cosmetics to protect the skin and maintain an attractive
appearance; many benefits may be derived from this practice.
Because increasing numbers of aging individuals are seeking cosmetic
surgery, gerontological nurses will find it beneficial to be informed of the
various types of surgical interventions. Nurses can also help patients locate
competent cosmetic surgeons. Patients need to be aware that not all
surgeons are skilled in cosmetic surgery, and some unfortunate
complications have resulted from unskilled physicians performing cosmetic
surgery or injecting patients with collagen or silicone. Nurses should also
explore patients’ reasons for seeking cosmetic surgery to ensure that it is a
rational decision rather than a symptom of an underlying problem, such as
depression or a neurotic disorder; counseling and therapy may be a more
pressing need than surgical intervention in some circumstances. Perhaps as
society achieves a greater acceptance and understanding of the aging
process, the masking of the effects of aging with cosmetics and surgery will
be replaced by an appreciation of the natural beauty of age.
POINT TO PONDER
How much of your self-concept is based on your physical appearance?
How do you anticipate reacting to the physical manifestations of aging?
Direct contact with patients allows nursing staff to detect skin problems
that may not be apparent to other health care professionals. It is important
for nurses to regularly assess patients’ skin status (Assessment Guide 25-1)
and identify nursing diagnoses (Nursing Problem Table 25-1) and problems
in need of referral for medical attention. Because serious complications,
such as new pressure injuries, can result from undetected skin problems,
astute attention to skin status is crucial.
TABLE 25-1 Nursing Problems Related to Dermatologic
Problems

SKIN STATUS
Much of the status of the integumentary system is evident to the naked
eye. A quick observation can assist in evaluating skin color, moisture, and
cleanliness, and the presence of lesions. Signs such as pallor or flushing
can provide clues to health problems.
INTERVIEW
Ask the patient about itching, burning sensations on the skin surface, and
other symptoms associated with skin problems. Also use this opportunity
to review bathing and shampooing practices.
Skin surface. Examine the entire skin surface from head to toe,
including behind the ears, within skin folds, under the breasts, and
between the toes. Bathing and massages are good opportunities to
inspect the skin in the course of patient care. Note moles, skin tears,
bruises, discoloration, and any other unusual finding. Be aware that
areas of pressure may be difficult to detect in dark-skinned persons.
Lesions. Describe any lesions as specifically as possible in regard to
their color (e.g., purple, black, and hypopigmented), configuration
(e.g., linear, separate, confluent, and annular), size (e.g., measurement
of depth and diameter), drainage, and type. Terms used to describe
the types of lesions include the following:
Macule: a small nonpalpable spot or discoloration
Papule: a discoloration less than ½ cm in diameter with palpable
elevation
Plaque: a group of papules
Nodule: a lesion ½ to 1 cm in diameter with palpable elevation;
the skin may or may not be discolored
Tumor: a lesion greater than 1 cm with palpable elevation; the
skin may or may not be discolored
Wheal: a red or white palpable elevation that may occur in
variable sizes
Vesicle: a lesion less than ½ cm in diameter that contains fluid
and has a palpable elevation
Bulla: a lesion greater than ½ cm in diameter that contains fluid
and has a palpable elevation
Pustule: a lesion containing purulent fluid; of variable size and
palpable elevation
Fissure: a groove in the skin
Ulcer: an open depression in the skin that may occur in variable
sizes
Mongolian spots . Consider that many persons of African, Asian, or
Native American backgrounds have Mongolian spots. These are
irregular, dark areas (resembling bruises) that may be found on the
buttocks, lower back, and to a lesser extent on the arms, abdomen,
and thighs.
Skin turgor . Test skin turgor by gently pinching various areas of the
skin. Skin turgor tends to be poor in most older adults; however, the
areas over the sternum and forehead do experience less of an age-
related reduction in turgor and are good areas for turgor assessment.
Pressure tolerance. Assess pressure tolerance by inspecting a
pressure point after the patient has been in the same position for half
an hour; if redness is present, the patient must be on a turning
schedule of every half an hour. If redness is not present, allow the
patient to remain in the same position for 1 hour and inspect; if
redness is not apparent, increase increments by half an hour up to 2
hours.
Temperature. Obtain a gross assessment of skin temperature by using
the back of the hands and touching various areas. Note coldness or
temperature inequalities between the extremities.
SELECTED SKIN CONDITIONS
Pruritus
The most common dermatologic problem among older adults is pruritus.
Although atrophic changes alone may be responsible for this problem,
pruritus can be precipitated by any circumstance that dries the person’s
skin, such as excessive bathing and dry heat. Diabetes, arteriosclerosis,
hyperthyroidism, uremia, liver disease, cancer, pernicious anemia, and
certain psychiatric problems can also contribute to pruritus. If not corrected,
the itching may cause traumatizing scratching, leading to breakage and
infection of the skin. Prompt recognition of this problem and
implementation of corrective measures are, therefore, essential. If possible,
the underlying cause should be corrected. Careful assessment is required to
assure conditions, such as scabies, that demand special precautions are not
present. Bath oils, moisturizing lotions, and massage are beneficial in
treating and preventing pruritus. Vitamin supplements and a high-quality,
vitamin-rich diet may be recommended. Topical application of zinc oxide is
effective in controlling itching in some individuals. Antihistamines and
topical steroids may also be prescribed for relief.
CONSIDER THIS CASE

Seventy-year-old Mrs. J is a well-dressed,
attractive woman who appears younger than her actual age. She mentions
to you that she was widowed earlier this year and has begun to date. “I
tend to be attracted to younger men, and many of them like being with a
mature woman,” she comments. “I had a facelift when I was 55 and
looked great, so I’m thinking about having another one so that I can look
young again.”
THINK CRITICALLY
1. How would you respond to Mrs. J?
2. What advice could you give her?
KEY CONCEPT
Excessive bathing and dry heat dry the skin and can promote pruritus.
Keratosis
Keratoses , also referred to as actinic or solar keratoses, are small, light-
colored lesions, usually gray or brown, on exposed areas of the skin.
Keratin may be accumulated in these lesions, causing the formation of a
cutaneous horn with a slightly reddened and swollen base. Freezing agents
and acids can be used to destroy the keratotic lesions, but electrodesiccation
or surgical excision ensures a more thorough removal. Close nursing
observation for changes in keratotic lesions is vital because these lesions are
precancerous.
Seborrheic keratoses are dark, wart-like projections on the skin (Fig. 25-1).
Older adults commonly have these lesions on various parts of their bodies.
The lesions may be as small as a pinhead or as large as a quarter. They tend
to increase in size and number with age. In the sebaceous areas of the trunk,
face, and neck and in persons with oily skin, these lesions appear dark and
oily; in less sebaceous areas, they are dry in appearance and of a light color.
Normally, seborrheic keratoses will not have swelling or redness around
their base. Sometimes abrasive activity with a gauze pad containing oil will
remove small seborrheic keratoses. Larger, raised lesions can be removed
by freezing agents or by a curettage and cauterization procedure. Although
these lesions are benign, medical evaluation is important to differentiate
them from precancerous lesions. In addition, the cosmetic benefit of
removal should not be overlooked for the older patient.
FIGURE 25-1 Seborrheic keratoses. (Reprinted with
permission from Rosenthal, T. C., Williams, M. E., &
Naughton, B. J. (2006). Office care geriatrics (Fig. 36-2).
Philadelphia, PA: Lippincott Williams & Wilkins.)
Skin Cancer
There are three major skin cancers that are common in late life: basal cell
carcinoma, squamous cell carcinoma, and melanoma. Basal cell carcinoma,
the most common form of skin cancer, grows slowly and rarely
metastasizes. Risk factors for its development include advanced age and
exposure to the sun, ultraviolet radiation, and therapeutic radiation. It
commonly occurs on the face, although it can erupt anywhere on the body.
The growths tend to be small, dome-shaped elevations covered by small
blood vessels that often resemble benign, flesh-colored moles with a
“pearly” surface (Fig. 25-2A). The surface sometimes is dark, rather than
shiny, if the growth contains melanin pigments.
FIGURE 25-2 Common types of skin cancer. A. Basal
cell carcinoma. B. Melanoma. (Reprinted with permission
from Rosenthal, T. C., Williams, M. E., & Naughton, B. J.
(2006). Office care geriatrics (Figs. 36-19 and 36-25).
Philadelphia, PA: Lippincott Williams & Wilkins.)
As the name implies, squamous cell carcinoma arises in the squamous
cells that are on the surface of the skin, the lining of the hollow organs of
the body, and the passages of the respiratory and digestive tracts. Sun
exposure is the most prevalent factor contributing to the development of
this cancer, although some less common factors (e.g., exposure to
hydrocarbons, arsenic, and radiation) can facilitate its growth. Squamous
cell carcinoma can develop in scar tissue and is also associated with
suppression of the immune system. These cancers typically appear as firm,
skin-colored or red nodules. Squamous cell carcinoma usually stays in the
epidermis but can metastasize; the lower lip is a common site of metastasis.
Melanoma tends to metastasize, or spread, more easily than the other
forms of skin cancer, making it more deadly if not caught early. The
incidence of melanomas has been rising in the United States, probably due
to sun exposure. Fair-skinned individuals are at higher risk for melanomas
than the general population, and the incidence increases with age.
Melanomas can be classified as follows:
Lentigo maligna melanoma. This black, brown, white, or red

pigmented flat lesion occurs predominately on sun-exposed areas of
the body. With time, it enlarges and becomes progressively irregularly
pigmented. The mean age at diagnosis is 67.
Superficial spreading melanoma. Most melanomas are of this type.
The lesion appears as variable pigmented plaque with an irregular
border. It can occur on any area of the body. Its incidence peaks in
middle age and continues to be high through the eighth decade.
Nodular melanoma. This melanoma can be found on any body surface
and presents as a darkly pigmented papule that increases in size over
time.
Acral lentiginous melanoma. This type typically appears on the palms
of the hands, soles of the feet, and under nail beds. It is not related to
sun exposure and tends to occur on people with darker skin.
Suspicious lesions should be evaluated and biopsied (Fig. 25-2B).

Usually, melanomas are excised with removal of some of the surrounding
tissue and subcutaneous fat. Some physicians recommend removal of all
palpably enlarged lymph nodes. The prognosis depends on the depth of the
melanoma rather than the type.
Nurses should teach older adults to inspect themselves for melanomas,
identify moles that demonstrate changes in pigmentation or size, and seek
evaluation of suspicious lesions. Early detection improves the prognosis.
Vascular Lesions
Age-related changes can weaken the walls of the veins and reduce the
veins’ ability to respond to increased venous pressure. Obesity and
hereditary factors compound this problem. Weakened vessel walls cause
varicose veins. The poor venous return and congestion that result lead to
edema of the lower extremities, which leads to poor tissue nutrition. As the
poorly nourished legs accumulate debris, inadequately carried away with
the venous return, the legs gain a pigmented, cracked, and exudative
appearance. Stasis dermatitis, an inflammatory condition associated with
chronic venous insufficiency, can result. Subsequent scratching, irritation,
or other trauma (which can result from tight elastic-band stockings) that
occurs with stasis dermatitis can then easily lead to the formation of leg
ulcers. These ulcers, known as stasis ulcers, often appear on the medial
aspect of the tibia above the malleolus and, prior to skin breakdown, present
as a dark discoloration of the skin.
Stasis ulcers need special attention to facilitate healing. Infection must
be controlled, and necrotic tissue removed before healing will occur. Good
nutrition is an important component of the therapy, and a diet high in
vitamins and protein is recommended. Once healing has occurred, concern
should be given to avoiding situations that promote stasis dermatitis. The
patient may need instruction regarding a diet for weight reduction or the
planning of high-quality meals. Venous return can be enhanced by elevating
the legs several times a day and by preventing interferences to circulation,
such as standing for long periods, sitting with legs crossed, and wearing
garters. Elastic support stockings may be prescribed and, although effective,
can be a challenge for some older adults to apply. The nurse needs to assess
the older adult’s ability to properly put on these stockings and provide
instruction as needed. Some patients may require ligation and stripping of
the veins to prevent further episodes of stasis dermatitis.
Pressure Injury
KEY CONCEPT
In 2016, the National Pressure Ulcer Advisory Panel (NPUAP) decided
upon a significant change in terminology. The term pressure ulcer was
replaced with pressure injury to more accurately represent pressure
injuries that affect intact and ulcerated skin. Some updates to the stages
of pressure injury were made, also.
Tissue anoxia and ischemia resulting from pressure can cause the
necrosis, sloughing, and ulceration of tissue. This is commonly known as a
pressure injury , previously called pressure ulcer. Box 25-1 describes the
recommended system for describing the stages of pressure injuries. This
staging system is used in the Minimum Data Set tool for assessing nursing
home residents.
BOX 25-1 Stages of Pressure Injury

DEEP TISSUE INJURY
A purple or maroon area of intact skin or a blood-filled blister due to
damage of underlying tissue. Area can be painful, firm or mushy, and
warm or cool. Can progress quickly and expose additional layers of
tissue.
STAGE 1
A persistent area of skin redness (without a break in the skin) that does
not disappear when pressure is relieved. Usually over a bony prominence
Stage 2
A partial-thickness loss of skin layers involving the epidermis that
presents clinically as an intact or open/ruptured blister, or open shallow
crater
STAGE 3
A full thickness of skin is lost extending through the epidermis and
exposing the subcutaneous tissues; presents as a deep crater with or
without tunneling and undermining adjacent tissue
STAGE 4
A full thickness of skin and subcutaneous tissue is lost, exposing muscle,
bone, or both; presents as a deep crater that may include necrotic tissue,
slough, or eschar. Tunneling and undermining often is present
UNSTAGEABLE
Full-thickness loss of tissue with the base covered by slough and/or
eschar. Stage cannot be determined until slough or eschar is removed to
expose the base and actual depth of wound.
DEEP TISSUE PRESSURE INJURY
Localized area of nonblanchable deep red or purple discoloration with a
dark wound bed or blood-filled blister due to intense or prolonged
pressure or shearing force. Skin may be intact or nonintact.
Any part of the body can develop a pressure injury, but the most
common sites are the sacrum, greater trochanter, and ischial tuberosities
(Fig. 25-3). Older adults are at high risk for pressure injury because they
FIGURE 25-3 Common locations for pressure sores when
supine and sitting. (Reprinted with permission from
Miller, C. (2019). Nursing for wellness in older adults (8th
ed., Fig. 23-2). Philadelphia, PA: Lippincott Williams &
Wilkins.)
Have skin that is fragile and damages easily

Are often in a poor nutritional state
Have reduced sensation of pressure and pain
Are more frequently affected by immobile and edematous conditions,
which contribute to skin breakdown
In addition to developing more easily in older persons, pressure injuries

require a longer period to heal than in younger people. Therefore, the most
important nursing measure is to prevent their formation; to do this, it is
essential to avoid unrelieved pressure. Encouraging activity or turning the
patient who cannot move independently is necessary. The patient’s
individual pressure tolerance (see Assessment Guide 25-1) determines the
frequency of turning; a turning schedule of every 2 hours may not be
sufficient for every patient, and pressure injuries can develop under that
turning schedule. Shearing forces that cause two layers of tissue to move
across each other should be prevented by not elevating the head of the bed
more than 30 degrees, not allowing patients to slide in bed, and lifting
instead of pulling patients when moving them. Use of pillows, floatation
pads, alternating pressure mattresses, and water beds can disperse pressure
from bony prominences. However, it must be emphasized that these devices
do not eliminate the need for frequent position changes. When sitting in a
chair, patients should be urged to move and should be assisted with shifting
their weight at certain intervals. Lamb’s wool and heel protectors are useful
in preventing irritation to bony prominences. The nurse should make sure
that sheets are kept wrinkle free and check the bed frequently for foreign
objects, such as syringes and utensils, which the patient may be lying on
unknowingly. Sensitivity also is needed when medical devices are being
used for diagnostic or therapeutic purposes (e.g., braces, BP cuffs) because
they can apply pressure, which can injure the skin.
KEY CONCEPT
Some older patients may develop signs of pressure injuries, even with a
turning schedule of every 2 hours, and require more frequent
repositioning.
A high-protein, vitamin-rich diet to maintain and improve tissue health

is also essential to avoid formation of pressure injury. Good skin care is
another essential ingredient in prevention. Skin should be kept clean and
dry; blotting the patient dry will avoid irritation from rubbing the skin with
a towel. Bath oils and lotions, used prophylactically, help keep the skin soft
and intact. Massage of bony prominences and range of motion exercises
promote circulation and help keep the tissues well nourished. The person
who is incontinent should be thoroughly cleansed with soap and water and
dried after each episode to avoid skin breakdown from irritating excreta.
COMMUNICATION TIP
Individuals can vary in regard to their skin status and risks for skin
breakdown, so it is important that caregivers understand the unique
risks and preventive measures for the persons they care for. The nurse
should review the individual patient’s risks and measures that can
reduce them. The nurse should not assume that because the caregiver
has completed nursing assistant training, the caregiver will understand
how actions are tailored to the individual patient or that the caregiver
has read and understood the care plan.
Once evidence of a pressure injury is noted, aggressive intervention is

necessary to avoid the multiple risks associated with this impairment of skin
integrity. Treatment measures depend on the state of the pressure injury as
identified by the following signs:
Hyperemia. Redness of the skin appears quickly and can disappear

quickly if pressure is removed. There is no break in the skin, and the
underlying tissues remain soft. Relieving the pressure by the use of a
square of adhesive foam is useful; it is advisable to protect the skin
with a product such as DuoDerm (Squibb) or Tegasorb (3M) before
applying the adhesive.
Ischemia. Redness of the skin develops from up to 6 hours of
unrelieved pressure and is often accompanied by edema and
induration. It can take several days for this area to return to its normal
color, during which the epidermis may blister. Skin should be
protected with Vigilon, which contains water and is soothing to the
area. If the skin surface is broken, it should be cleansed daily with
normal saline or the product suggested by your agency.
Necrosis. Unremitting pressure extending over 6 hours can cause
ulceration with a necrotic base. This type of sore requires a transparent
dressing that protects from bacteria but is permeable to oxygen and
water vapor. Thorough irrigation is essential during dressing changes.
Sometimes topical antibiotics are used. It may take weeks to months
for full healing to occur.
Deep tissue damage. If pressure is not relieved, necrosis will extend
through the fascia and potentially to the bone. Eschar, a thick,
coagulated crust, is frequently present, and bone destruction and
infection may occur. Unless eschar is removed, the underlying tissue
will continue to break down, so debridement is essential.
Because the risk of pressure injury formation is high among older

patients, it is wise for gerontological nurses to assess patients’ risk of
pressure injuries upon admission or first contact. Several tools that have
been used for several decades can assist in objective assessment of pressure
injuries risk, such as the Braden scale and the Norton scale (Agency for
Healthcare Research and Quality, 2014; Grazioli, 2019; Norton et al, 1962).
The Pressure Sore Status Tool (PSST) (Shirley Ryan AbilityLab, 2017) is
an instrument that offers a means for assessing and monitoring existing
pressure injuries using 13 indexes (e.g., size, exudate, necrotic tissue,
edema, and granulation). Depending on the patient population served and
types of clinical setting, agencies and facilities may develop their own tools
to assess risk and monitor pressure injuries.
KEY CONCEPT
Reverse staging of a pressure injury should not be done. As the injury
heals, refer to it as a “healing stage ___” and state the highest stage at
which the injury was assessed to be.
GENERAL NURSING
CONSIDERATIONS FOR SKIN
CONDITIONS
Promoting Normalcy
Psychological support can be especially important to the patient with a
dermatologic problem. Unlike respiratory, cardiac, and other disorders,
dermatologic problems are often visibly unpleasant to the patient and
others. Visitors and staff may unnecessarily avoid touching and being with
the patient in reaction to his or her skin problems. The nurse can reassure
visitors regarding the safety of contact with the patient and provide
instruction for any special precautions that must be followed. The most
important fact to emphasize is that the patient is still normal, with normal
needs and feelings, and will appreciate normal interactions and contact.
Many older adults are distressed at the visible signs of aging reflected
in wrinkles. Persons of all ages need to be advised that wrinkles can be
prevented by avoiding excess sun exposure and using a sunscreen. There
are topical products (e.g., α- or β-hydroxy acids) that can reduce wrinkling.
With cosmetic surgery advertisements being widespread, this option for
gaining a more youthful looking skin may be considered by some older
persons; advise individuals to seek reputable providers who are experienced
in these procedures.

For centuries, various herbs have been used to treat skin problems. Today,
the use continues, as evidenced by creams, lotions, and shampoos
containing aloe, chamomile, and other plant products. Aloe vera has
emollient properties when used externally, and many people find it useful
for treating minor cuts and burns. The external application of chamomile
extract is used for skin inflammation. Witch hazel has long been used for its
astringent effects and is applied externally for the treatment of bruises and
swelling.
Essential oils are also increasingly used for the prevention and
treatment of skin problems, including thyme oil as an antiseptic, thyme
linalool and rosewood oil for topical acne, rosemary oil for cell
regeneration, and the oils of basil, cinnamon, garlic, lavender, lemon, sage,
savory, and thyme for insect bites or stings. Topical application of
peppermint oil can have an anti-inflammatory effect and speed the healing
of wounds and mild burns.
Some homeopathic and naturopathic remedies are being used to treat
skin eruptions, as is acupuncture. Biofeedback, guided imagery, and
relaxation exercises can help control the symptoms of some dermatologic
disorders.
There is a belief that nutritional supplements can also be beneficial for
skin disorders; those most commonly recommended are zinc, magnesium,
essential fatty acids, and vitamins A, B complex, B6, and E. Nurses should
urge patients to discuss the use of alternative therapies with their
physicians.
Choosing a Support Surface for Pressure Injury

Prevention and Treatment
Source: McNichil, L., Mackey, D., Watts, C., & Zuecca, N. (2020). Nursing
2020, 50(2), 41–44.
An important way to help prevent pressure injuries is to redistribute
pressure on support surfaces other than the standard hospital bed. Although
this is an accepted principle, research is limited related to the type of
support surface that is most useful in preventing pressure injuries. Because
of this lack of guidance on suitable products, nurses typically make
decisions based on such factors as personal experience or health care setting
preference (based on cost). Due to the lack of evidence-based guidance for
choosing the best support service for pressure injury prevention, the Wound,
Ostomy and Continence Nurses Society (WOCN) launched a process for
developing a valid, reliable method for selecting the best support surface
based on patient risk and other characteristics.
In this study, 21 researchers, scientists, and clinicians with expertise in
support surfaces were asked to provide feedback related to best practices in
selecting support surfaces that were effective in redistributing pressure. It
was recognized that decision-making regarding the most appropriate
support surfaces had to be based on a comprehensive assessment, including
status and location of wounds (if present), the need for elevation of the head
of the bed, activity and positioning limitations, risk for falls and
entrapment, and the patient’s height and weight. In addition, the use of the
Braden scale to assess moisture and mobility was considered beneficial.
Based on the experts’ feedback, the researchers in this study developed an
algorithm to guide support surface selection. The nurse using the algorithm
responds to a series of questions to determine the patient’s risk of pressure
injury and the best support surface to use based on the patient’s condition.
(This guide is accessible from any mobile device at
http://algorithm.wocn.org/#home.)
Specific practices, supplies, and equipment are sometimes used because
they have a long tradition of use; in some cases, they are influenced by
purchasing decisions of nonclinical personnel. Although it is easy to accept
these practices, supplies, and equipment, there may be situations in which
they are currently not the best available or are not supported by evidence.
Nurses should critically evaluate practices, supplies, and equipment to
ensure they are evidence based and best serve the patient, especially
considering that practices and materials change, and new ones could yield
better results.
PRACTICE REALITIES
You are working in an intensive care unit and notice that although the
nursing staff is highly skilled in monitoring patients and providing complex
treatments, they are less attentive to changing patients’ positions and
checking skin status. It is not uncommon for older patients to develop
pressure injuries during their stay in the unit. You mention this to one of the
nurses who responds, “That is the least of their problems. Our concern is
keeping them alive.”
Although you appreciate the complexities of the care offered, you still
believe that patients should not be allowed to develop pressure injuries
while on the unit.
What can you do to address this issue while maintaining harmony with
coworkers?

1. Discuss the psychosocial implications of pressure injuries and
malignant melanoma.
2. Describe the method for determining an individualized turning
schedule.
3. Develop a protocol for the prevention of pressure injuries.

questions.
Nurse’s Notes
1400: Mr. Baldwin is a 93-year-old male admitted to the hospital from
home with a past medical history significant for lung cancer with
metastasis to the bone. Upon admission it is noted that the client is
incontinent for both urine and stool. An external male catheter is in
place. Admission assessment confirms a stage II sacral pressure injury
(PI) measuring 3 × 1.5 × 0.1 cm, 0% epithelial tissue, and mild
incontinence-associated dermatitis (IAD). Mr. Baldwin’s Braden score is
13. The client’s weakened, fragile state keeps him bedridden except for
occasional transfer to a chair. The patient’s pain is assessed on a scale of
0 to 10, with 0 being the absence of pain and 10 being severe pain. The
patient reports significant pain in his back, reports pain levels of 8 to 9
with repositioning, and consistently requests p.r.n. pain medication. Mr.
Baldwin’s vital signs are heart rate 70 beats per minute (bpm),
respiratory rate 20 breaths per minute (bpm), temperature 37.5°C
(99.6°F), blood pressure 100/64 mm Hg, and pulse oximetry 93% room
air.
Diagnostic procedures/results:
Prealbumin: 13
Albumin: 2.8
Blood urea nitrogen (BUN): 4 mg/dL
Body mass index (BMI): 18
White blood cells (WBC): 12,000/mc/L
Chapter Summary
The skin experiences many visible changes with age. An assessment of skin
condition can provide clues to conditions within the body.
Although seborrheic keratoses present more of a cosmetic problem than
a medical one, they must be differentiated from solar keratosis, which can
be precancerous and require close monitoring. Basal cell carcinoma,
squamous cell carcinoma, and melanoma are the major skin cancers in late
life.
Stasis dermatitis, associated with chronic venous insufficiency, can
easily lead to the development of stasis ulcers. Good nutrition and
prevention of infection facilitates their healing.
Pressure injuries are a significant concern for older adults, who can
develop them more easily. Assessment of risk factors and development of
plans to reduce them that are tailored to the unique risks of the individual
are essential nursing measures.
Because the skin condition and appearance is important to self-concept,
some aging individuals seek methods to address the wrinkles and lines that
develop with age. Nurses can refer people to reputable cosmetic surgeons
and assist them in evaluating the claims of skin care and antiaging products
to aid them in avoiding threats and prevent them from wasting resources.
Online Resources
Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality
of Care
https://www.ahrq.gov/sites/default/files/publications/files/putoolkit.pdf
American Academy of Facial and Reconstructive Plastic Surgery
https://www.aafprs.org/patient/procedures/proctypes.html
American Cancer Society/ Skin Cancer
https://www.cancer.org/cancer/skin-cancer.html
Braden Scale for Predicting Pressure Ulcer Risk
https://www.in.gov/isdh/files/Braden_Scale.pdf
National Arthritis and Musculoskeletal and Skin Diseases
https://www.niams.nih.gov/
National Pressure Injury Advisory Panel
https://npiap.org
Skin Cancer Foundation
https://www.skincancer.org
Wound, Ostomy, and Continence Nursing Society
https://www.wocn.org
References
Agency for Healthcare Research and Quality. (2014). Preventing pressure ulcers in hospitals: Section
7, tools and resources. Retrieved April 20, 2020 from https://www.ahrq.gov/patient-
safety/settings/hospital/resource/pressureulcer/tool/pu7b.html
Food and Drug Administration. (2019). Sunscreen: How to help protect your skin from the sun.
Retrieved April 22, 2020 from https://www.fda.gov/drugs/understanding-over-counter-
medicines/sunscreen-how-help-protect-your-skin-sun
Grazioli, A. (Ed.). (2019). Comprehensive geriatric assessment toolkit: Braden scale. Retrieved April
20, 2020 from https://www.cgakit.com/braden-scale
Norton, D., McLaren, R., & Exton-Smith, A. N. (1962). An investigation of geriatric nursing
problems in the hospital. London: National Corporation for the Care of Old People.
Shirley Ryan AbilityLab. (2017). Bates-Jensen wound assessment tool. Retrieved April 20, 2020
from https://www.sralab.org/rehabilitation-measures/bates-jensen-wound-assessment-tool
CHAPTER 26
Cancer
Chapter Outline
Aging and Cancer
Unique Challenges for Older Persons With Cancer
Risk Factors, Prevention, and Screening
Treatment
Nursing Considerations for Older Adults With Cancer
LEARNING OBJECTIVES
1. Discuss the prevalence and risks of cancer in the older population.

2. Describe reasons for cancer being more complex in older adults.
3. List factors that increase the risk of cancer.
4. Outline preventive measures that can reduce the risk of cancer in older
adults.
5. Describe increased risks for older adults receiving conventional cancer
treatment.
6. Discuss reasons for patients’ choice to use complementary and
alternative medicine (CAM).
7. List issues to evaluate in the selection of CAM for patients with cancer.
8. Discuss nursing considerations in caring for older patients with cancer.
TERMS TO KNOW
BRCA: breast cancer gene; blood tests can be done to identify mutations
in either one or two breast cancer susceptible genes (BRCA1 and
BRCA2)
CAMcomplementary and alternative medicine therapies; those therapies
that fall outside of mainstream Western medical practices; includes
alternative medical systems, mind–body interventions, manipulative
and body-based methods, biologically based therapies, and energy
therapies
SPFsun protection factor rating used for sunscreens to indicate the
protection they offer from sun
Caring for older adults with cancer is a nearly inescapable aspect of

gerontological nursing. Cancer is a disease of older people, being the
second leading cause of death in persons aged 65 years and older (Centers
for Disease Control and Prevention, 2019). Most new cases are diagnosed
in older adults, and the probability of developing this disease dramatically
increases with advancing age. The National Cancer Institute acknowledges
that age is the single most important risk factor for cancer. Cancer rates
increase from childhood on, with the most dramatic increases being in late
life. Even if there were no increase in cancer rates, the prevalence of cancer
in older adults will rise in the future as the older population continues to
grow.
KEY CONCEPT
More than half of the persons diagnosed with cancer are over age 65
years.
Gerontological nurses have a significant role to play in the prevention,

diagnosis, and treatment of cancer. Encouraging healthy lifestyle habits in
persons of all ages can help reduce the risk factors for developing cancer.
Educating patients about cancer screening and facilitating their efforts to
obtain tests can enable cancers to be detected in early stages, thereby
increasing survival rates. Creative, holistic, and skillful nursing
interventions that offer support—physical, emotional, and spiritual—to
individuals diagnosed with cancer and their significant others promote the
best possible quality of life in the presence of the disease.
AGING AND CANCER
Unique Challenges for Older Persons With

Cancer
Cancer in any age group presents many clinical challenges; however, in
older adults, the complexities are even greater. Despite having the highest
rate of most cancers, older adults have the lowest rate of receiving early
detection tests; thus, their disease may be in an advanced stage when
diagnosed. In addition, it is the rare older adult who does not have another
health condition (e.g., heart disease, diabetes mellitus, arthritis, or chronic
obstructive pulmonary disease) present when diagnosed with cancer. The
presence of multiple health conditions elevates the risk of complications,
disability, and death for older patients diagnosed with cancer. Further,
concern regarding how the older patient’s already compromised organs will
tolerate chemotherapy, and other cancer therapies could impact treatment
decisions. Survival rates for older adults are lower than in younger persons
for most types of cancer, even if they are diagnosed at the same stage.

As mentioned, cancer primarily is a disease of old age, but why is that so?
There are two major theories that attempt to explain the increased incidence
of cancer with age. The first has to do with biological, age-related changes
that impair the ability to resist diseases. This theory is supported by
decreases in the mitochondrial activity of the cell that reduce its ability to
resist cancer. Changes in the immune system (reduced T-cell activity,
interleukin-2 levels, and mitogen responsiveness) impair the body’s ability
to recognize cancerous cells and destroy them.
Prolonged exposure to carcinogens over the years is another
explanation for the rising incidence of cancer with age. This is
demonstrated by the growth of melanomas on the skin of persons who have
had chronic exposure to damaging ultraviolet rays and the development of
lung cancer in industrial workers who regularly breathed toxic substances.
Although the extent of responsibility that either age-related changes or
exposure has in the development of cancer cannot be clearly stated at this
time, it is evident that aging adults face an increased risk of developing
cancer; therefore, the reduction of risk factors is beneficial.
KEY CONCEPT
The increased incidence of cancer with age could result from age-related
changes that reduce the ability to resist the disease or prolonged
exposure to carcinogens.
RISK FACTORS, PREVENTION, AND

SCREENING
The risk factors for cancers offer insights into some of the preventive
measures that could prove useful in avoiding these diseases. Many cancers
can be prevented by healthy lifestyle practices that minimize risks. Box 26-
1 connects risk factors with some preventive measures that nurses can
incorporate into health education and counseling.
BOX 26-1 Cancer Risk Factors and Actions to

Reduce Risk
Avoid the use of and exposure to tobacco products.
Cigarette smoking is the leading cause of lung cancer death in both men
and women. Smoking is also responsible for one third of all cancer
deaths and for most cancers of the larynx, oral cavity, and esophagus. It
is highly associated with the development of, and deaths from, bladder,
kidney, pancreatic, and cervical cancers (National Cancer Institute,
2017).
Limit exposure to the sun. Use sunscreens (rated between 15 and 30
SPF [sun protection factor]) and avoid sunbathing.
Repeated exposure to ultraviolet rays from the sun, sunlamps, and
tanning beds can increase the risk of skin cancer, particularly in persons
with fair skin.
Eat a diet rich in fiber, fruits, and vegetables; limit intake of red
meats, fats, fried foods, and pickled, smoked, or cured foods.
Researchers have discovered that people who ate diets high in animal fat
and low in fruits and vegetables had higher rates of stomach and
colorectal cancer than those who ate low–animal fat diets
(Thanikachalam & Khan, 2019). Additional studies have shown that an
increased risk of developing pancreatic and breast cancer is associated
with high intakes of well-done, fried, or barbecued meats.
Maintain weight within an ideal range; exercise and be physically
active.
Obesity increases the rates of cancer of the prostate, pancreas, uterus,
colon, and ovary and breast cancer in older women. Exercise could
decrease the risk of breast cancer.
Protect against exposure to known carcinogens.
The contamination of drinking water from nitrate, a chemical used in
fertilizers, has been associated with an increased risk of non-Hodgkin’s
lymphoma (Yu et al., 2020). The risk is directly correlated with the level
of nitrates consumed and is particularly high in rural areas. Vegetables
high in nitrate content do not carry the same risk.
Before the 1950s, x-rays were used to treat acne, ringworm of the scalp,
and enlarged thymus, tonsils, and adenoids. This exposure to radiation
increases the risk of thyroid cancer. Exposure to asbestos, nickel,
cadmium, uranium, radon, vinyl chloride, benzene, and other substances
also can increase the risk of cancer.
Radon can enter homes through cracks in the foundation. In areas
without adequate ventilation, radon gas can accumulate to levels that
substantially increase the risk of lung cancer (Environmental Protection
Agency, 2020).
Limit alcohol consumption.
Heavy alcohol consumption increases the risk of cancer of the mouth,
throat, esophagus, larynx, and liver.
Discuss chemoprevention with your physician if family history
increases the risk of cancer.
Inherited alterations in the genes called BRCA1 and BRCA2 (short for
breast cancer 1 and breast cancer 2) are involved in many cases of
hereditary breast and ovarian cancer. The risk that BRCA1 or BRCA2 is
associated with these cancers is highest in women with a family history
of multiple cases of breast cancer, with at least one family member
having two primary cancers at different sites, or who are of Eastern
European (Ashkenazi) Jewish background (Komen, 2020).
Women have special risks. Because most breast and ovarian cancers
occur in women over age 50 years, increased age is a factor (American
Cancer Society, 2019a). In addition, women who had their first menstrual
period before the age of 12 years or experienced menopause after age 55
years have a slightly increased risk of breast cancer, as do women who had
their first child after age 30 years. Women who have a first-degree relative
(mother, sister, or daughter) or other close relative with breast and/or
ovarian cancer may be at increased risk for developing these cancers.
Women whose mothers took diethylstilbestrol during pregnancy have an
increased risk of vaginal cancer (American Cancer Society, 2020). In
addition, women with relatives who have had colon cancer are at increased
risk for developing ovarian cancer. Excess estrogen is suspected to
contribute to breast cancer because of its natural role in stimulating breast
cell growth. Long-term hormonal replacement therapy may increase a
woman’s risk of breast and ovarian cancer, although research is
inconclusive at this time.
Gerontological nurses need discretion to sort through risk factors, so
that while promoting positive health habits, they do not alarm patients with
unsupported claims. For instance, some people think that because stress and
other “toxic” emotions can depress immune function, they also can
contribute to cancer. Evidence currently does not conclusively support this
relationship. Another example is the fear many people have that artificial
sweeteners cause cancer, but this link has not been proven (American
Cancer Society, 2019b; Oncology Nurse Advisor, 2018). Nor has the
National Cancer Institute proved any link between coffee and cancer,
another common belief. Further, there is no clear evidence that food
additives are risk factors for cancer.
In addition to preventive measures, nurses should educate older adults
about cancer screening, an important measure to improve outcomes in
patients who develop cancer. Early detection can improve prognosis of
cancer and should be encouraged for persons of all ages. Medicare provides
reimbursement for screening tests for breast, cervical, colorectal, and
prostate cancers. Some of the recommended tests are outlined in Box 26-2.
BOX 26-2 Recommended Cancer Screening for

Older Adults
Mammogram and clinical breast examination every 2 years until
age 75 unless there is more than an average risk for breast cancer
Screening for colorectal cancer until age 75; between ages 75 and
85 years, consult with physician as to advisability of testing
Lung cancer screening with low-dose CT up to age 75 years for
those with a 30-pack per year smoking history, those who currently
smoke, or persons who have quit within the past 15 years
PSA tests for men aged 70 years and older may not be necessary;
men with a life expectancy of 10 years or more should discuss
benefits and risks with their health care provider
Cervical cancer screening after age 65 years not necessary if there
have been normal test results for past 10 years; if there is a history
of serious cervical precancer, screening should continue for 20
years after that diagnosis
Source: American Cancer Society (2020). Cancer screening guidelines by age . Retrieved
from https://www.cancer.org/healthy/find-cancer-early/cancer-screening-guidelines/screening-
recommendations-by-age.html
COMMUNICATION TIP
It is beneficial to assess the attitude of older patients or their health
care proxies about cancer screening and treatment. Decisions made by
these patients or proxies might not conform to the nurse’s assessment.
For instance, the decision may be made to forego breast cancer
screening and treatment because a patient is in her 70s, when the
health status and life expectancy of the patient could support the value
of these actions. Another example could be an 88-year-old patient, his
or her family, or health care proxy, who may desire treatment for a
newly diagnosed lung cancer even though the patient’s poor general
health status and life expectancy cause this treatment to present more
risks than benefits for the patient. Nurses can sensitively share facts,
clarify misconceptions, discuss treatment goals, address questions, and
assure decisions are informed ones. Such discussions are more
effective and relevant if rapport and trust have been established with
the patient or health care proxy.
TREATMENT
The plan of treatment depends on the specific cancer; however, most
conventional forms of treatment include surgery, radiation, chemotherapy,
and biologic therapy. Although the same basic care measures apply to older
patients undergoing these treatments as to adults of any age, there are some
unique risks. Persons over age 70 years have a higher risk of mortality and
complications from all surgeries, and this risk is heightened with emergency
or unplanned surgeries, as can occur with an unexpected detection of a
mass. Advanced age can affect the pharmacokinetics and
pharmacodynamics of cytotoxic drugs and increase the risk of
complications (e.g., cardiotoxicity, neurotoxicity, and myelodepression).
Doses need to be adjusted carefully to account for altered glomerular
filtration rates and other differences. Fortunately, there is no significant
difference between the older persons and adults of other ages in the ability
to tolerate radiation therapy.
POINT TO PONDER
What would be your primary concerns if you faced treatment for cancer?

Special diets, acupuncture, psychotherapy, spiritual practices, vitamin
supplements, and herbal remedies are among the complementary and
alternative medicine ( CAM ) therapies that are used by many people with
cancer (National Center for Complementary and Integrative Health, 2020).
CAM therapies often are attractive to patients with cancer because of the
healing philosophies and approaches used. CAM practitioners tend to have
a holistic orientation and are not only concerned with treating the disease
but also likely to be equally, if not more, concerned with caring for the
whole person. CAM practitioners offer the following:
Relationship-centered care: They invest the time in learning about the

unique characteristics of patients and enter a unique journey with each
patient.
Support: Learning to live with cancer is challenging and demanding.
Even if the malignant cells are eliminated, emotional and spiritual pain
may be present. CAM practitioners provide unconditional acceptance
and understanding of patients “where they are.”
Healing partnerships: CAM practitioners honor patients’ rights to
control their care and their lives, seeing their role as empowering,
facilitating, and supporting patients in the healing process.
Comfort: Many CAM therapies are high touch (i.e., “hands-on”
therapies such as massage, therapeutic touch, healing touch) and
relieve stress and discomfort. Practitioners provide psychological
comfort as they take the time to listen, to reassure, and to be
emotionally available.
Hope: Particularly when conventional medicine has exhausted its
treatments, CAM practitioners provide options that can offer hope and
encouragement through knowing that something is being attempted.
Patients can heal—that is, feel a sense of wholeness and live the best
possible quality of life—despite having an incurable disease.
POINT TO PONDER
Why might you seek complementary and alternative therapies if you or a
loved one were diagnosed with cancer?
Although CAM can contribute to a patient’s care, it is unwise for

patients to use these therapies without carefully weighing risks and benefits.
The labels natural or holistic do not ensure that the therapy is safe or the
best option for the patient for his or her given circumstances. Box 26-3
offers some questions that nurses can use in assisting patients in evaluating
CAM. Nurses can provide a useful service to patients in helping them to
research claims made by promoters of therapies and products to treat
cancer. The National Cancer Institute and National Center for
Complementary and Alternative Medicine (see Resource listings) can offer
assistance in evaluating CAM claims.
BOX 26-3 Questions to Ask When Evaluating a

Complementary and Alternative Therapy
What is the purpose or expected outcome of the therapy?
Is the therapy compatible with other treatments being used?
Will serious delays in seeking or using conventional treatment
result from using complementary and alternative medicine?
Is special training, licensure, or certification required by
practitioners of the therapy, and if so, is the practitioner being
considered to provide the therapy qualified?
What risks are associated with the therapy? Do the risks outweigh
the benefits?
What are the expected side effects?
What is the cost?
How many treatments will be needed; how long will the product
need to be used?
Is the therapy covered by any health insurance?
What research exists supporting the therapy? How large have the
studies been, what were their quality, how many people
participated, and who has conducted them?
Is the therapist willing to offer the names of other patients who have
used his or her service?
Are there any “red flags” (e.g., secretive nature of treatment,
unwillingness to disclose ingredients of product, necessity to travel
to a foreign country to obtain treatment, requirement that all other
treatments be discontinued)?
Knowledge about CAM is rapidly growing, and today’s hypotheses

could be proved or disproved tomorrow. Nurses are challenged to stay
current of this expanding field so that they can integrate CAM into their
practice safely and effectively. It also is important to assure patients do not
forego sound conventional treatment for CAM approaches that may not
have been shown to have the same effectiveness.
KEY CONCEPT
Ask about the use of CAM during every assessment, and encourage
patients to inform their physicians of all therapies and products being
used.

OLDER ADULTS WITH CANCER

Gerontological nurses have a commitment to promoting healthy aging. One
means of demonstrating this is to increase awareness of measures that can
pre vent cancer (see Box 26-1). Opportunities for educating individuals can
range from teaching formal group classes to discussing options for change
when risk factors are identified during individual assessments. This
education need not be limited to older adults. Cancer prevention to younger
people can promote a healthier senior population in the future.
Nurses play an important role in ensuring that patients understand the
warning signs of cancer. The American Cancer Society’s use of the word
CAUTION, in which each letter represents the first letter of a warning sign,
provides a useful way to remember them:
Change in bowel or bladder habits

A sore that does not heal
Unusual bleeding or drainage
Thickening or lump in the breast or elsewhere
Indigestion or swallowing difficulty
Obvious change in a wart or mole
Nagging persistent cough or hoarseness
In addition, nurses assess patients’ knowledge of self-examination for

cancer (e.g., breast examination, testicular examination, and skin
inspection) and provide instruction as needed. For the patient who is unable
to perform self-examinations, the nurse develops a plan for caregivers to
perform these examinations for the patient on a regular schedule. It is
important to enquire about dates of last cancer screening tests and refer for
testing as needed.

When the diagnosis of cancer is made, the nurse can help the patient to
obtain the best possible care. Some oncology centers may specialize in a
particular cancer and be able to offer more options to patients than other
facilities. Also, as appropriate, the nurse assists patients in contacting the
National Cancer Institute to learn about clinical trials that may be
beneficial.
Older adults receiving radiation and chemotherapy require the same
basic care and face the same general risks as adults of any age who undergo
these treatments; oncology nursing literature should be consulted for
guidance. However, the challenges with older adults may be increased
because of common age-related factors that contribute to increased risks of
malnutrition, dehydration, constipation, immobility, impaired skin integrity,
and infection. Close monitoring and taking actions to prevent complications
(e.g., reporting changes in vital signs or increased fatigue) are essential.
A significant fear associated with cancer is pain. Patients need to be
assured that pain can be managed. The nurse should regularly assess for
pain and assist in developing a plan to prevent and manage pain. (See
Chapter 13 for discussion of comfort measures.)
Further information about specific types of cancers appears in other
chapters, for example, cancer of the colon (Chapter 18), prostate (Chapter
20), lung (Chapter 16), stomach (Chapter 18), testes (Chapter 20), and
pancreas (Chapter 18).

The diagnosis of cancer can be considerably overwhelming and stressful to
many patients. Older adults may recall the grim experiences of people with
cancer they have known throughout their lives—people who were
diagnosed years ago when treatment options were considerably more
limited than today—and fear that their outlook will be similar. They may
fear that they will experience pain, deformity, and lost independence. The
cost of treatment could present significant burdens to patients and their
families. Plans and pursuits may have to be forfeited as treatment of the
disease takes center stage. Patients will need strong support during this
time. It is important to consult with the physician to learn about the
patient’s diagnosis, treatment plan, and prognosis. The nurse assesses the
patient’s understanding, clarifies misconceptions, and offers explanations
where needed. Providing ample opportunity for the patient to express
feelings is important.
Family and significant others may share the patient’s concerns and have
additional concerns of their own. For example, a wife may worry that the
cost of her husband’s treatment or his death will place her in a financially
vulnerable position. Or a daughter may grieve that her parent may not
survive to see her marry. They, too, need support. (Local chapters of the
American Cancer Society can provide information on support groups for
people with cancer and their loved ones.)
KEY CONCEPT
Remember that the diagnosis of cancer touches lives beyond the
patient’s.
CONSIDER THIS CASE

Sixty-two–year-old Carrie S has been diagnosed
with breast cancer and after having a lumpectomy has begun
chemotherapy. She has been optimistic and eager to progress with her
treatment. During one of her treatments, she is accompanied by her 55-
year-old sister. The sister appears quite anxious. She shares that her
mother had breast cancer at age 65 years and lived until age 82 years,
when she died of lung cancer. “Now,” she says, “Carrie has the disease,
and I know I’m next in line.” She tells you that she is “thinking of having
bilateral mastectomies to avoid the fate of my mother and sister.”
THINK CRITICALLY
1. How would you react to the sister’s concerns?
2. How could her sister’s feelings potentially affect Carrie S?
3. What support can you offer Ms. S?
Patients may experience a variety of reactions as they cope with their

disease, including depression, grief, guilt, anger, bargaining, and
acceptance. Similar to the grief experienced with the dying process, they
may float in and out of various stages at different times. Sensitivity to the
patient’s emotional and spiritual status during each encounter is essential.
The nurse must remember that family members may experience these same
fluctuations in emotions.
Physical, emotional, and spiritual support are required by patients with
terminal cancer as they cope with potentially many challenges (Box 26-4).
The needs of these patients and their families can change and demand
regular reassessment and adjustment to the plan of care. Chapter 36 offers
guidelines for end-of-life care that are applicable to patients with terminal
cancer.
BOX 26-4 Possible Nursing Problems of

Patients With Terminal Cancer
Pain
Reduced physical activity
Malnutrition
Sleep disturbance
Irritation of oral cavity
Risk for infection
Disruption in family relationships
Social isolation
Inability to engage in meaningful activities
Depression
Grief
Need for information/education
Fatigue
Fear
Questioning of faith
Suicide Risk After Cancer Diagnosis Among

Older Adults: A Nationwide Retrospective Cohort
Study
Source: Choi, J. W., & Park, E. C. (2020). Journal of Geriatric Oncology,
11(5), 814–819. Retrieved from
https://pubmed.ncbi.nlm.nih.gov/31787493/?
from_term=cancer+in+older+adults&from_sort=date&from_page=45&fro
m_pos=7
A cancer diagnosis can be devastating for persons of any age, including
older adults. The impact of a diagnosis of cancer can increase the risk of
suicide; however, despite the reality that half the cancers occur in older
adults, little is known about suicide in older adults with cancer. This study
aimed to learn about suicide risk in older adults within the first year
following their diagnosis.
Using the National Health Insurance Service Senior Cohort data,
259,688 older persons between the ages of 62 to 115 years were sampled.
The patients with a diagnosis of cancer had a much higher suicide rate
within the first year after diagnosis than those without cancer. The risk was
highest among patients who had a known mental disorder prior to their
diagnosis of cancer.
Often, a patient’s physical status and the existence of physical diseases
are considered when the patient is diagnosed with cancer as a means to
determine tolerance for various cancer treatments. However, it also is
essential to assess mental and emotional well-being and a past history of
mental disorders. Specific enquiry should be made as to a history of
depression and suicidal thoughts, how the patient feels about and is coping
with the cancer diagnosis, concerns, current suicidal thoughts, and support
systems. The best plan for surgery, chemotherapy, or radiation therapy will
have no value if unidentified and unaddressed depression or other
psychiatric problems lead the patient to suicide.
PRACTICE REALITIES
Sixty-two–year-old Ms. Strand has been diagnosed with breast cancer. She
has visited the oncology department where you work, and the oncologist
has recommended chemotherapy, radiation, and a lumpectomy. A very
attractive single woman, Ms. Strand expressed concern about the effects of
the treatments on her appearance. When she misses her next appointment
and fails to contact the office, you call her to reschedule her appointment.
She tells you she isn’t going to have the recommended therapies as she has
found an alternative practitioner who claims he can cure her of her cancer
with a special diet, supplements, and positive thinking exercises. “I can
treat my cancer, improve my general health, and I won’t have to get cut,
burned, or go bald,” she says with excitement.
What could you do in this situation?

1. Develop an outline of the content for a health education program for a
senior citizen group on “cancer prevention, risks, and diagnosis.”
2. Describe current lifestyle factors that may affect the risk of cancer in
future generations of older persons.
3. Develop a plan of care for an older adult diagnosed with lung cancer
that integrates conventional and CAM therapies.
4. What actions could nurses take in their communities to reduce cancer
risks?

questions.
Susan Janes is a 65-year-old who is presenting at a woman’s clinic for
her annual check-up. Nurse’s Notes
1200: Mrs. Janes’ medical history includes a ruptured appendectomy at
age 6, two vaginal deliveries, and she was diagnosed as prediabetic 2
years ago. The client states she has “smoked just a couple of cigarettes a
day since I was about 20.” The client denies drinking any alcohol,
saying, “I don’t like the taste of any of it.” Mrs. Janes worked outdoors at
a local nursery for 20 years prior to retiring 8 months ago. She reports no
incidence of cancer in her immediate family, but several members of her
extended family have been diagnosed with various forms of cancer. Her
assessment results include body mass index (BMI) 25, blood pressure
114/72 mm Hg (on beta blocker), respiratory rate 16 breaths per minute
and regular, pulse oximetry 94%, heart rate 76 beats per minute and
regular, and temperature 98.4°F (36.9°C) oral.
Chapter Summary
Although cancer is the older population’s second leading cause of death,
this group has a low rate of receiving early detection tests and, when
diseases are diagnosed, they tend to be in an advanced stage. This fact
emphasizes the need to assess for signs of cancer, advise about
recommended screening, and educate about measures to reduce cancer risks
and identify signs of cancer when providing services to older persons.
Older adults do have a higher rate of mortality and complications from
cancer treatments. The risks and benefits in light of remaining life
expectancy need to be considered when making treatment decisions.
Despite their increased risk for complications, older adults who are in good
health should not avoid cancer screening or fear treatment just because of
their age.
In addition to the conventional treatments of surgery, radiation, and
chemotherapy, CAM is used by many persons with cancer. Although CAM
therapies can offer comfort and support to patients, they should not be
substituted for effective conventional therapies.
Because the diagnosis of cancer can be devastating for patients and
their families, support and guidance from nurses are highly beneficial. A
holistic approach should be used to address total needs.
Online Resources
American Cancer Society
https://www.cancer.org
National Breast Cancer Foundation
https://www.nationalbreastcancer.org
National Cancer Institute
https://www.cancer.gov
1-800-4-CANCER (1-800-422-6237)
TTY (for deaf and hard of hearing callers): 1-800-332-8615
https://www.nccih.nih.gov
National Comprehensive Cancer Network
https://www.nccn.org
References
American Cancer Society. (2019a). Cancer facts for women. Retrieved April 21, 2020 from
http://www.cancer.org/healthy/findcancerearly/womenshealth/cancer-facts-for-women
American Cancer Society. (2019b). Aspartame. Retrieved March 20, 2015 from
https://www.cancer.org/cancer/cancer-causes/aspartame.html
American Cancer Society. (2020). Risk factors for vaginal cancer. Retrieved April 21, 2020 from
https://www.cancer.org/cancer/vaginal-cancer/causes-risks-prevention/risk-factors.html
Centers for Disease Control and Prevention. (2019). 10 Leading causes of death by age group,
United States. Retrieved April 20, 2020 from
https://www.cdc.gov/injury/wisqars/pdf/leading_causes_of_death_by_age_group_2018-508.pdf
Environmental Protection Agency. (2020). Radon. Retrieved April 23, 2020 from
http://www.epa.gov/radon/pubs/citguide.html
Komen, S. G. (2020). Genetic counseling and genetic testing. Retrieved April 21, 2020 from
http://ww5.komen.org/BreastCancer/GeneMutationsampGeneticTesting.html
National Cancer Institute. (2017). Harms of smoking and health benefits of quitting. Retrieved April
20, 2020 from http://www.cancer.gov/about-cancer/causes-prevention/risk/tobacco/cessation-
fact-sheet
National Center for Complementary and Integrative Health. (2020). 6 Things you need to know about
cancer and complementary health approaches. Retrieved April 22, 2020 from
https://www.nccih.nih.gov/health/tips/things-you-need-to-know-about-cancer-and-
complementary-health-approaches
Oncology Nurse Advisor. (2018). Artificial sweeteners and cancer risk (Fact Sheet). Retrieved Aril
21, 2020 from https://www.oncologynurseadvisor.com/home/cancer-types/general-
oncology/artificial-sweeteners-and-cancer-risk-fact-sheet/
Thanikachalam, K., & Khan, G. (2019). Colorectal cancer and nutrition. Nutrients , 11 (1). Retrieved
April 22, 2020 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6357054/.
Yu, M., Li, C., Hu, C., Jin, J., Qian, S., & Jin, J. (2020). The relationship between consumption of
nitrite or nitrate and risk of non-Hodgkin lymphoma. Scientific Reports , 10 (551). Retrieved
April 22, 2020 from https://doi.org/10.1038/s41598-020-57453-5.
CHAPTER 27
Mental Health Disorders
Chapter Outline
Aging and Mental Health
Promoting Mental Health in Older Adults
Selected Mental Health Conditions
Depression
Anxiety
Substance Abuse
Paranoia
Nursing Considerations for Mental Health Conditions
LEARNING OBJECTIVES
1. Describe the realities of mental health and illness in older adulthood.

2. List measures that promote mental health for older adults.
3. Describe the symptoms and care of the older adult with depression.
4. Identify indications of suicidal thoughts in older adults.
5. Describe interventions to reduce anxiety in older adults.
6. Discuss the scope and signs of substance abuse in the older population.
7. Describe factors to consider when antidepressant medications are used
by older adults.
8. Describe factors that promote a positive self-concept in older adults.
9. Identify nursing actions to manage disruptive behavior associated with
mental health conditions in older adults.
TERMS TO KNOW
Emotional homeostasisbalance of emotions
Pseudodementiafalse appearance of dementia that occurs when persons
demonstrate cognitive deficits secondary to being depressed
Substance abuseinappropriate or excessive use of alcohol, caffeine,
cannabis, hallucinogens, inhalants, opioids, sedatives, hypnotics,
anxiolytics, stimulants, tobacco, and other or unknown substances that
result in disorders
Mental health indicates a capacity to cope effectively with and manage

life’s stresses in an effort to achieve a state of emotional homeostasis .
Older people have an advantage over other age groups in that they probably
have had more experience with coping, problem-solving, and managing
crises by virtue of the years they have lived. Most older adults have few
delusions regarding what they are or what they are going to be. They know
where they have been, what they have accomplished, and who they really
are. Immigrating to a new country, watching loved ones die from
epidemics, fighting in world wars, and surviving the Great Depression may
be among the numerous stresses that today’s older adults have faced and
overcome. Such experiences have provided them with unique strength that
should not be underestimated.
However, acknowledging this strength does not imply that psychiatric
illness is not a problem among the older adult population. People are living
long and, hence, may bring to their later years the mental health problems
they have possessed throughout their lifetimes. In addition, the many losses
and challenges of late life may exceed the physical, emotional, and social
resources of some persons and contribute to mental illness. By promoting
mental health, detecting problems early, and minimizing the impact of
existing psychiatric problems, nurses can help older people achieve optimal
quality of life and function.
KEY CONCEPT
What does mental health mean to you?
AGING AND MENTAL HEALTH

Myths prevail regarding mental health and older adults. For instance, many
people still believe, incorrectly, that loss of cognitive functioning,
“senility,” or mental incompetence is a normal part of aging. Descriptions
of older adults being childlike, rigid, or cantankerous propagate stereotypes
about personality in later life. Frequently, these misconceptions and ageist
views are so widely accepted that when an older adult demonstrates
pathological signs, it is considered normal and no attempt is made to
intervene. Nurses can play a significant role in ensuring that the differences
between myths and realities of mental health in old age are understood.
Mental health in later life is highly individualized, based on personal
resources, health status, and the unique experiences of the individual’s life.
The incidence of mental disorders among older adults is rising. One in four
older adults experiences some mental disorder such as depression, anxiety
disorders, substance use disorders, and dementia. The number is expected to
double to 15 million by 2030. Two thirds of older adults with mental health
problems do not seek treatment. Depression affects seven million older
Americans. People aged 85 and above have the highest rate of suicide of
any age group, with older white men having a suicide rate almost six times
that of the general population (National Council on Aging, 2018). Loss of
multiple loved ones, altered sensory function, and alterations, discomforts,
and demands associated with multiple chronic conditions that older adults
frequently encounter set the stage for a variety of mental health problems.
KEY CONCEPT
Mental health among older adults is highly individualized based on their
health status, experiences, and personal resources.
PROMOTING MENTAL HEALTH IN
OLDER ADULTS
Mental health in older adulthood implies a satisfaction and interest in life.
This can be displayed in a variety of ways, ranging from silent reflection to
zealous activity. The quiet individual who stays at home does not
necessarily have less mental health capacity or mental health than does the
person who is actively involved in every possible community program.
There is no single profile for mental health; thus, assessment of an older
individual’s mental health should be objective and unbiased.
Good mental health practices throughout an individual’s lifetime
promote good mental health in later life. To preserve mental health, people
need to maintain the activities and interests that they find satisfying. They
need opportunities to sense their value as a member of society and to have
their self-worth reinforced. Security through the provision of adequate
income, safe housing, the means and access to meet basic human needs, and
support and assistance through stressful situations will promote mental
health. Connection and socialization with others is also an aspect of mental
health. Finally, a crucial component in the preservation and promotion of
mental health is the importance of optimum physical health.
KEY CONCEPT
Good mental health practices throughout the life span promote good
mental health in older adulthood.
Nurses must recognize that there are times in everyone’s life when
disturbances occur that alter the capacity to manage stress. The same
principles guiding the care of physical health problems can be applied to the
care of persons with mental health problems. The following are actions
related to those principles that can be used in care:
Strengthen the individual’s capacity to manage the condition: fostering
improvement of physical health, good nutrition, increased knowledge,
meaningful activity, stress management, income supplements, and
socialization
Eliminate or minimize the limitations imposed by the condition:
providing consistency in care, not fostering hallucinations, reality
orientation, correction of physical problems, and modifying the
environment to compensate for deficits
Act for or do for the individual only when absolutely necessary:
selecting an adequate diet, assisting with bathing, administering
medications, managing finances, and coordinating activities for the
patient
Mental health conditions must be seen in the perspective of the patient’s

total world. Older adults confront many problems that challenge their
emotional homeostasis, such as the following:
Illness: coping, related self-care demands, pain, altered function or

body image
Death: friends, family, pets, significant support person
Retirement: loss of status, role, income, social network, sense of
purpose
Increased vulnerability: crime, illness, disability, abuse
Social isolation: lack of transportation, funds, health, friends
Sensory deficits: decrease in or loss of function of hearing, vision,
taste, smell, and touch
Greater awareness of own mortality: declining health, increased
number of deaths among peers
Increased risk of institutionalization, dependency: loss of self-care
capabilities to varying degrees
With these factors in mind, some of the symptoms displayed may be

normal reactions to the circumstances at hand (Fig. 27-1). Before labeling
the patient with a psychiatric diagnosis, the nurse should explore such
factors in the patient’s behavior and address the cause of the problem rather
than its effects alone.
FIGURE 27-1 Astute assessment of behavior and
cognitive function aids in differentiating symptoms of
psychiatric illness from normal reactions to life events.
Astute assessment can help distinguish normal reactions to life events

from mental health conditions (Assessment Guide 27-1). Table 27-1
outlines potential nursing problems that assessment may reveal.
TABLE 27-1 Nursing Problems Related to Mental Health

Problems
MENTAL HEALTH
Assessment of mental status and mental health actually begins the moment
the nurse meets the patient. Upon initial observation, pay attention to the
following indicators of mental health:
Grooming and dress: Is clothing appropriate for the season, clean and
presentable, appropriately worn? Is the patient clean? Is the hair clean
and combed? Are makeup and accessories appropriate or excessive or
bizarre?
Posture: Does the patient appear stooped and fearful? Is body
alignment normal?
Movement: Are tongue rolling, twitching, tremors, and/or hand
wringing present? Are movements hyperactive or hypoactive?
Facial expression: Are facial expressions masklike or overly
dramatic? Are there indications of pain, fear, or anger?
Level of consciousness: Does the patient drift into sleep and need to
be aroused (i.e., lethargic)? Does the patient offer only incomplete or
slow responses and need repeated arousal (i.e., stuporous)? Are
painful stimuli the only thing the patient responds to (i.e.,
semiconscious)? Is there no response, even to painful stimuli (i.e.,
unconscious)? While observing the patient, general conversation can
aid in evaluating mental status.
Note the tone of voice, rate of speech, ability to articulate, use of

unusual words or combinations of words, and appropriateness of speech.
Also assess mood during this time.
Does the patient make good eye contact when talking?

Does the patient engage in conversation?
Does the patient show interest in activities and in the questions
asked? Does the patient answer questions in detail or in short
responses?
Does the patient answer yes/no questions with a yes/no or “I don’t
know”?
INTERVIEW
Effective questioning can reveal much about the patient’s mental health.
Ask direct questions to unveil specific problems, such as the following:
“How do you feel about yourself? Would you say others would say
you are a good or bad person?”
“Do you have many friends? How do you get along with people?”
“Has anyone harmed you or do you feel that anyone is trying to harm
you? Who? Why?”
“Are you moody? Do you quickly go from laughing to crying or from
being happy to sad?”
“Do you have trouble falling asleep or staying asleep? How much
sleep do you get? Do you use any drug or alcohol to help you sleep?”
“How is your appetite? How do your appetite and eating pattern
change when you are sad or worried?”
“Do you ever have feelings of being nervous, such as palpitations,
hyperventilating, and restlessness?”
“Are there any particular problems in your life or anything you are
concerned about now?”
“Do you see or hear things that other people do not? Have you ever
heard voices? If so, how do you feel about them?”
“Does life bring you pleasure? Do you look forward to each day?”
“Have you ever thought about suicide? If so, what were those ideas
like? How would you do it?”
“Do you feel you are losing any of your mental abilities? If so,
describe how.”
“Have you ever been hospitalized or had treatment for mental
problems? Has any member of your family?”
Listen carefully to the answers and how they are given. It is important
to pick up nonverbal clues.
COGNITIVE AND MOOD TESTING
A variety of reliable, validated tools can be used in assessing mental
function, such as the Short Portable Mental Status Questionnaire (Pfeiffer,
1975) and Mini-Mental State Exam (MMSE) (Folstein, Folstein, &
McHugh, 1975), Mini-Cog (Borson, Scanlan, Chen, & Ganguli, 2003), St.
Louis University Mental Status (SLUMS) Examination (Tariq, Tumosa,
Chibnall, Perry III, & Morley, 2006), and the Montreal Cognitive
Assessment (Nasreddine et al., 2005). Evidence-based assessment tools for
depression include the Zung Self-Rating Depression Scale (Zung, 1965)
and Geriatric Depression Scale (Sheikh & Yesavage, 1986; Yesavage et
al., 1983). Most mental status evaluation tools test orientation, memory
and retention, the ability to follow commands, judgment, and basic
calculation and reasoning.
It is best to use an evidence-based tool so nurses and interprofessionals
can consistently monitor for changes over time. However, even without
the use of a tool, the nurse can assess basic cognitive function in the
following ways:
Orientation: Ask the patient what the patient’s name is, where the
patient is, the date, time, and season.
Memory and retention: At the beginning of the assessment, ask the
patient to remember three objects (e.g., watch, telephone, and boat).
First, ask the patient to recall the items immediately after being told;
then, after asking several other questions, ask for recall of the three
items again; near the end of the assessment, ask what the three items
were one last time.
Three-stage command: Ask the patient to perform three simple tasks
(e.g., “Pick up the pencil, touch it to your head, and hand it to me.”).
Judgment: Present a situation that requires basic problem-solving and
reasoning (e.g., “What is meant by the statement ‘A bird in the hand
is worth two in the bush’?”).
Calculation: Ask the patient to count backward from 100 by
increments of 5; if this is difficult, ask the patient to count backward
from 20 by increments of 2. Simple arithmetic problems may also be
asked, if they are within the realm of the patient’s educational
experience.
Whenever cognitive function and mood are assessed, consider the
unique experiences, educational level, and cultural background of the
patient, as well as the role of sensory deficits, health problems, and the
stress associated with being examined.
Persons with Alzheimer’s disease or other cognitive deficits may
become overwhelmed by the assessment and react with anger, tears, or
withdrawal. This is referred to as a catastrophic reaction. The assessment
may need to be discontinued temporarily and the patient reassured and
comforted.
Physical health problems are often at the root of many cognitive and
mental health disturbances. For example, depression can be related to
diabetes, adrenal disease, congestive heart failure, tumors, strokes,
Parkinson’s disease, and other medical conditions. Because of the potential
for medical conditions to cause depression, it is essential that a complete
physical examination supplements the mental status evaluation. A
complete review of known diagnoses and medications being used is
crucial. In addition, a variety of laboratory tests may be conducted,
including the following:
complete blood count

serum electrolytes
serologic test for syphilis
blood urea nitrogen
blood glucose
bilirubin and other liver function tests
blood vitamin levels
erythrocyte sedimentation rate
urinalysis
Depending on the problem suspected, cerebrospinal fluid may be

tested and a variety of diagnostic procedures performed, including
electroencephalography, computed tomography, magnetic resonance
imaging, and positron emission tomography scan. The mental status
evaluation often presents only a snapshot of the individual. Cerebral blood
flow, body temperature, blood glucose, fluid and electrolyte balance, and
the stress to which the patient is subjected can change from one day to the
next. Repeated assessments may be necessary to obtain an accurate and
comprehensive evaluation of the patient’s mental status.
SELECTED MENTAL HEALTH

CONDITIONS
Depression
Depression is the most frequent problem that psychiatrists treat in older
adults, and although major depression declines with advanced age, minor
depression increases in incidence with age. The presence of depressive
symptoms is more common among older adults than a diagnosis of major
depressive disorder (American Psychiatric Association, 2013). Various
estimates have placed the prevalence of depressive symptoms at 15% in
community-based older adults. Major depressive disorder is estimated in
6% to 10% of community-based older adults, 12% to 20% of nursing home
residents, and 11% to 45% of acute care older adult patients (Resnick,
2019).
Although depressive episodes may have been a lifelong problem for
some individuals, it is not uncommon for depression to be a new problem in
older adulthood. This is understandable when one considers the adjustments
and losses older adults face, such as the independence of one’s children; the
reality of retirement; significant changes or losses of roles; reduced income
restricting the pursuit of satisfying leisure activities and limiting the ability
to meet basic needs; decreasing efficiency of the body; a changing self-
image; the death of family members and friends, reinforcing the reality of
one’s own shrinking life span; and overt and covert messages from society
that one’s worth is inversely proportional to one’s age. In addition, drugs
can cause or aggravate depression (Box 27-1).
BOX 27-1 Drugs That Can Cause Depression

Antihypertensives and cardiac drugs: β-blockers, digoxin,
procainamide, guanethidine, clonidine, reserpine, methyldopa,
spironolactone
Hormones: corticotropin, corticosteroids, estrogens
Central nervous system depressants, antianxiety agents : alcohol,
haloperidol, flurazepam, barbiturates, benzodiazepines
Others: cimetidine, l-dopa, ranitidine, asparaginase, tamoxifen
COMMUNICATION TIP
Every comprehensive assessment includes an evaluation of mental
status and mood. Because patients may be anxious, embarrassed,
suspicious, or insulted by having their mental status reviewed, explain
the importance of and the reasons for the examination. Approach the
evaluation in a matter-of-fact manner, not in an apologetic or
intimidating one, with reassurance that this evaluation is part of every
patient’s assessment. Position yourself at the same level as the patient
and make eye contact. Communicate on a level and with language
appropriate for the patient. Provide ample time for the patient to
respond because it may take the older patient longer to process the
question, recall the information, and form the response. Making the
patient comfortable and establishing rapport before the assessment can
reduce some of the barriers to an effective mental health examination.
Signs and Symptoms

Depression is a complex syndrome and is demonstrated in a variety of ways
in older adults. The most common manifestations of depression include
insomnia, fatigue, anorexia, weight loss, constipation, lack of interest in
activities previously enjoyed, and decreased interest in sex. Depressed
persons may express self-deprecation, guilt, apathy, remorse, hopelessness,
helplessness, and feelings of being a burden. They may have problems with
their personal relationships and social interactions and lose interest in
people. Changes in sleep and psychomotor activity patterns can be evident.
Hygienic practices may be neglected. Physical complaints of headache,
indigestion, and other problems often surface. Altered cognition may be
present, caused by malnutrition or other effects of the depression. The
symptoms of depression can mimic those of dementia; thus, careful
assessment is crucial to avoid misdiagnosis. However, a decline in intellect
and personality may be more indicative of dementia (see Chapter 28), not
depression. Depression can occur in the early stage of dementia as the
patient becomes aware of declining intellectual abilities.
KEY CONCEPT
Some older adults who are depressed demonstrate cognitive deficits
secondary to the effects of depression. This pseudodementia can delay
or prevent the underlying depression from being recognized and treated.
The prevalence and risk of depression in older adults reinforces the

importance of assessing for this problem during routine health visits. Short
assessment tools such as the Geriatric Depression Scale-Short Form, can
assist in this process (Box 27-2).
BOX 27-2 Geriatric Depression Scale: Short

Form
Choose the best answer for how you have felt over the past week:
1. Are you basically satisfied with your life? YES/NO

2. Have you dropped many of your activities and interests? YES/NO
3. Do you feel that your life is empty? YES/NO
4. Do you often get bored? YES/NO
5. Are you in good spirits most of the time? YES/NO
6. Are you afraid that something bad is going to happen to you?
YES/NO
7. Do you feel happy most of the time? YES/NO
8. Do you often feel helpless? YES/NO
9. Do you prefer to stay at home, rather than going out and doing new
things? YES/NO
10. Do you feel you have more problems with memory than most?
YES/NO
11. Do you think it is wonderful to be alive now? YES/NO
12. Do you feel pretty worthless the way you are now? YES/NO
13. Do you feel full of energy? YES/NO
14. Do you feel that your situation is hopeless? YES/NO
15. Do you think that most people are better off than you are?
YES/NO
Answers in bold indicate depression. Score 1 point for each bolded

answer.
A score > 5 points is suggestive of depression.

A score > 10 points is almost always indicative of depression.
A score > 5 points should warrant a follow-up comprehensive
assessment.
From Yesavage, J. A., Brink, T. L., Rose, T. L., Lum, O., Huang, V., Adey, M. B., & Leirer, V.
O. (1983). Development and validation of a geriatric depression screening scale: A
preliminary report. Journal of Psychiatric Research , 17 , 37–49. Retrieved from
http://www.journalofpsychiatricresearch.com/article/0022-3956(82)90033-4/abstract
Older Native Americans, African Americans, and Asian Americans

have been found to have lower rates of diagnosed depression, believed to be
associated with missed identification or misdiagnosis (McKenzie & Sexson,
2021). Rather than provider bias, this can be attributed to poor reporting of
symptoms, language barriers, individuals’ beliefs that admitting to
depression is shameful or reflects weakness, distrust, or other factors.
Missed diagnosis can delay the treatment that could be beneficial in
promoting self-care and quality of life; therefore, nurses and other providers
need to be alert to atypical presentation of symptoms (e.g., physical
complaints, decline in physical health status due to inattention to health
practices, reports of fatigue, feelings of helplessness, unusual risk taking,
and self-imposed isolation) and explore the potential for depression being
the root cause.
The relationship of life events to the depression is essential to explore
during the assessment; the approach for a person depressed from the effects
of a drug obviously will differ from that for a person who has just become
widowed. The underlying problem should be addressed. Although
depressions do tend to last longer in older adults, prompt treatment can
hasten recovery. Treatment should be provided for depression associated
with a serious or terminal illness; alleviating the depression may help the
individual cope more effectively and be in a better position to manage other
health problems.
Treatment
Psychotherapy and antidepressants (Box 27-3) can alleviate many
depressions to varying degrees. Electroconvulsive therapy has been shown
to be effective in patients who have serious depressions that have been
unresponsive to other therapies. Some herbs have been promoted to have
antidepressant effects. These include St. John’s wort, which has been shown
to be effective for mild depressive symptoms; it can cause photosensitivity
and should not be used with an antidepressant medication. Acupressure,
acupuncture, guided imagery, and light therapy, in conjunction with
psychotherapy, can prove helpful. Good basic health practices, including
proper nutrition and regular exercise, can also have a positive effect on
mood. Box 27-4 describes other helpful nursing measures.
BOX 27-3 Antidepressants

Selective Serotonin Reuptake Inhibitors
Escitalopram (Lexapro)
Fluvoxamine (Luvox)
Fluoxetine (Prozac)
Paroxetine (Paxil)
Sertraline (Zoloft)
Cyclic Compounds
Amoxapine (Asendin)
Desipramine HCl (Norpramin, Pertofrane)
Doxepin HCl (Adapin, Sinequan)
Imipramine pamoate (Tofranil)
Nortriptyline HCl (Aventyl, Pamelor)
Monoamine Oxidase Inhibitors

Phenelzine (Nardil)
Tranylcypromine (Parnate)
Nursing Guidelines
Dosages for older adults should begin at the lowest dose and
frequency for any new medication.
Sedation commonly occurs during the initial few days of treatment;
take precautions to reduce the risk of falls.
At least 1 month of therapy is needed before therapeutic effects may
be noted; advise and support the patient, family, and caregivers
during this period.
Bedtime administration is preferable with antidepressants that
produce a sedative effect.
Prepare patients for adverse drug events including dry mouth,
diaphoresis, urinary retention, indigestion, constipation,
hypotension, blurred vision, drowsiness, increased appetite, weight
gain, photosensitivity, and fluctuating blood glucose levels. Assist
patients in preventing complications secondary to adverse drug
events.
Be alert to anticholinergic symptoms, particularly when cyclic
compounds are used.
Ensure that older adults and their caregivers understand dosage,
intended effects, and adverse reactions to the drugs. Instruct about
drug–drug and drug–food interactions, for example, antidepressants
can increase the effects of anticoagulants, atropine-like drugs,
antihistamines, sedatives, tranquilizers, narcotics, and levodopa;
antidepressants can decrease the effects of clonidine, phenytoin, and
some antihypertensive medications; alcohol and thiazide diuretics
can increase the effects of antidepressants.
BOX 27-4 Nursing Considerations in Caring

for Depressed Patients
Help the patient develop a positive self-concept. Emphasize that,
although the situation may be bad, the person is not. Provide
opportunities for success, regardless of how minor, and suggest
forming new goals as appropriate.
Encourage the expression of feelings. Express feelings of anger,
guilt, frustration, and other feelings. Nurses should afford time to
listen and guide patients through these feelings. In addition to
verbalization, feelings can be expressed through writing.
Avoid minimizing feelings. Statements such as “Don’t worry, things
will get better” or “Don’t talk that way; you have a lot to be
thankful for” offer little benefit to depressed persons.
Ensure that physical needs are met. Good nutrition, activity, sleep,
and regular bowel movements are among the factors that enhance a
healthy physical state, which in turn strengthen the patient’s
capacities to work through depression and other mental health
conditions. Assess and act on any known physical care problems.
Offer hope. While being realistic regarding the individual situation,
nurses can, by words and actions, convey their belief that the future
will have meaning and that the patient’s life is of value.
Suicide Risk
Suicide is a real and serious risk among depressed persons and older adults.
According to the National Center for Health Statistics (2018), males have a
higher rate of suicide than do females at all ages. Suicide rates for males
were highest among those aged 75 and over in both 2000 (42.4 per 100,000
males) and 2016 (39.2). The suicide rate in 2016 for males aged 75 and
over (39.2) was significantly lower than the rate in 2000 (42.4) but still
remains high. The suicide rates for females aged 65 to 74 were significantly
higher (p < 0.5) in 2016 (6.2 per 100,000 females) than in 2000 (4.0). The
suicide rates for females aged 75 and over were higher, though
nonsignificantly so, in 2016 (4.2) compared to 2000 (4.0) (National Center
for Health Statistics, 2018). Risk factors for suicide include previous
suicide attempt(s), family history of suicide, history of alcohol and/or
substance abuse, isolation, barriers to accessing mental health treatment,
physical illness, easy access to lethal methods, and unwillingness to seek
help (CDC, 2019). Protective factors include access and effective clinical
care for mental, physical, and substance abuse disorders; family and
community support; skills in problem solving, conflict resolution, and
nonviolent ways of handling disputes; as well as cultural and religious
beliefs that discourage suicide (CDC, 2019). All suicide threats from older
adults should be taken seriously and assessed thoroughly. Nurses need to
ask about any suicide attempts and subsequent treatment and follow-up.
This will help engage conversation, establish trust, and hopefully prevent a
potential future suicide attempt.
KEY CONCEPT
All suicide threats from older adults should be taken seriously.
Medication misuse, in the form of either overdoses or omission of

dosages, may be a suicidal gesture. Self-starvation is another sign and can
occur even in an institutional setting if staff members are not attentive to
monitoring intake and nutritional status. Engaging in activities that oppose a
therapeutic need or threaten a medical problem (e.g., ignoring dietary
restrictions or refusing a particular therapy) may indicate a desire to die.
Walking through a dangerous area, driving while intoxicated, and
subjecting oneself to other risks can also be signals of suicidal desires.
Suicidal risk can further be assessed by asking the patient about recent
losses, lifestyle changes, new or worsening health problems, new symptoms
of depression, changes in or a limited support system, and a family history
of suicide, prior suicidal attempts, and any plan in mind to attempt suicide.
It should be realized that a reasonably expressed “rational suicide” doesn’t
mean that the individual can’t benefit and regain a will to live through
counseling, support, improved quality of life, and treatment (Brauser,
2015).
Suicidal older adults need close observation, careful protection, and
prompt therapy. Treatment of the underlying depression should be
supported. The environment should be made safe by removing items that
could be used for self-harm. Nurses need to convey a willingness to listen
to and discuss thoughts and feelings about suicide. Being able to reach out
for help by expressing their suicidal thoughts to nursing staff may prevent
patients from taking actions to end their lives.
Anxiety
Adjustments to physical, emotional, and socioeconomic limitations in old
age and the new problems that frequently are encountered with aging add to
the variety of causes for anxiety. Anxiety reactions, common in older
adults, can be manifested in various ways, including somatic complaints,
rigidity in thinking and behavior, insomnia, fatigue, hostility, restlessness,
chain-smoking, pacing, fantasizing, confusion, and increased dependency.
An increase in blood pressure, pulse, respirations, psychomotor activity, and
frequency of voiding may occur. Appetite may increase or decrease.
Anxious individuals often handle their clothing, jewelry, or utensils
excessively; become intensively involved with a minor task (e.g., folding a
piece of linen); and have difficulty concentrating on the activity at hand.
Treatment of anxiety depends on its cause. Nurses should probe into the
patient’s history for recent changes or new stresses (e.g., new diagnosis or
worsening of existing one, rent increase, increased neighborhood crime, and
divorce of child). The consumption of caffeine, alcohol, nicotine, and over-
the-counter drugs should be reviewed for possible causes. In addition to
drugs, interventions such as biofeedback, guided imagery, relaxation
therapy, and psychological therapy can prove helpful. Anxious persons need
their lives to be simplified and stable, with few unpredictable occurrences.
Environmental stimuli must be controlled. Nurses should plan interventions
specific to the underlying cause. Basic nursing interventions that could
prove beneficial include the following:
Allow adequate time for conversations, procedures, and other

activities.
Encourage and respect patients’ decisions over matters affecting their
lives.
Prepare patients for all anticipated activities.
Provide thorough, honest, and basic explanations.
Control the number and variety of persons with whom patients must
interact.
Adhere to routines.
Keep and use familiar objects.
Prevent overstimulation of the senses by reducing noise, using soft
lights, and maintaining a stable room temperature.
KEY CONCEPT
What types of situations cause you to become depressed or anxious?
What implications does this have for your senior years?
Substance Abuse
As the number of people reaching late life increases, so does the number of
people with a history of alcohol and other substance use. This situation is
compounded by the fact that the baby boomers, a generation that
experimented with and accepted the use of illicit drugs, are reaching their
senior years and bringing their substance use and its effects with them.
The Diagnostic and Statistical Manual’s classification of Substance
Abuse and Addictive Disorders includes those disorders resulting from the
use of alcohol, caffeine, cannabis, hallucinogens (phencyclidine or similarly
acting arylcyclohexylamines), other hallucinogens such as LSD, inhalants,
opioids, sedatives, hypnotics, anxiolytics, stimulants (including
amphetamine-type substances, cocaine, and other stimulants), tobacco, and
other or unknown substances (American Psychiatric Association, 2013).
Substance-related disorders can include substance use disorders in which
the person uses the substance despite experiencing problems from it and
substance-induced disorders that include intoxication, withdrawal, and
substance-induced mental conditions such as psychosis, anxiety, and
delirium.
Abuse of, dependency on, or addiction to alcohol or other substances
among older adults often goes unnoticed, sometimes because it is
unexpected and sometimes because it mimics symptoms of common
geriatric conditions. Substance abuse can seriously threaten the physical,
emotional, and social health of older adults. Older adults who combine
alcohol or illegal drugs while taking prescription medications increase their
risk of adverse drug consequences. They also increase their risk of falls,
reduced cognitive function, abuse, and self-neglect. It is important that
gerontological nurses recognize this problem and help patients seek
appropriate treatment.
Most older adults who are substance abusers have used these substances
heavily throughout their lives. A significant number of chronic abusers die
before reaching old age, contributing to a decreased incidence of alcoholism
and other substance abuse with age. The other type of older substance
abuser is the one who begins abusing in late life because of situational
factors (e.g., retirement, widowhood, or poor health status).
Health care professionals may possess the same stereotype of substance
abusers as some people in the general public, believing them to be sloppy,
or lower-class types of people. Consequently, even professionals may fail to
detect substance abuse in the retired professional who smokes a joint after
dinner or the frail widow who begins sipping brandy at midmorning. Nurses
need to remain objective and recognize that substance abusers come in
many forms. In addition, substance abuse can cause medical problems, such
as gastrointestinal bleeding, hypertension, muscle weakness, peripheral
neuropathy, and susceptibility to infections. This reinforces the importance
of reviewing a history of substance abuse as part of the total assessment.
KEY CONCEPT
Substance abusers come in many forms and often do not fit the
stereotypical profile.
Alcohol Use or Misuse

Alcohol use or misuse may be manifested in a variety of ways, some of
which may be subtle or easy to confuse with other disorders (Box 27-5).
Symptoms can develop secondary to complications from alcoholism, such
as cirrhosis, hepatitis, and chronic infections (related to suppressed immune
system). These signs should be noted during an assessment and trigger
questions regarding the patient’s drinking pattern. The Short Michigan
Alcohol Screening Test—Geriatric Version (SMAST-G) (Blow et al., 1992)
and Alcohol Use Disorders Identification Test (AUDIT) (Babor, Higgins-
Biddle, Saunders, & Monteiro, 2001) are screening tools that have proven
effective at identifying alcohol abuse in older adults. Box 27-6 describes the
criteria for a definitive diagnosis of alcoholism.
BOX 27-5 Possible Indications of Alcohol

Abuse
Drinking alcohol to calm nerves or improve mood
Gulping or rapidly consuming alcoholic beverages
Memory blackouts
Malnutrition
Confusion
Social isolation and withdrawal
Disrupted relationships
Arrests for minor offenses
Anxiety
Irritability
Depression
Mood swings
Lack of motivation or energy
Injuries, falls
Insomnia
Gastrointestinal distress
Clumsiness
BOX 27-6 Criteria for Diagnosing Alcoholism

Drinks a fifth of whiskey a day or its equivalent in wine or beer (for
a 180-lb person)
Alcoholic blackouts
Blood alcohol level greater than 150 mg/100 mL
Withdrawal syndrome: hallucinations, convulsions, gross tremors,
delirium tremens
Continued drinking despite medical advice or problems caused by
drinking
Ongoing supervision of the older alcoholic’s health status can help

identify and, in some cases, correct complications early. Chronic alcoholism
can cause magnesium deficiencies, gastritis, pancreatitis, and
polyneuropathy. Cardiac disorders can result from alcoholism and can be
displayed by hypertension, irregular heartbeat, and heart failure due to
cardiomyopathy. Cognition can be impaired by a loss of brain cells and
enlargement of the ventricles.
In caring for the patient who has an alcohol problem, the long-term goal
is sobriety; this can be achieved only if the patient acknowledges the
problem and takes responsibility for doing something about it. Family
involvement can be significant to the success of the treatment plan because
outcomes can be negatively affected by loved ones denying or enabling the
drinking problem.
The National Institute of Alcohol Abuse and Alcoholism (NIAAA,
2017), therefore, recommends that alcohol consumption for adults age 65
and older be limited to 1 standard drink (12 ounces of beer, 4 to 5 ounces of
wine or 11⁄2 ounces of distilled spirits) per day, or 7 standard drinks per
week, and no more than 3 drinks per occasion. Lessened amounts or
abstinence are recommended for those taking medications that interact with
alcohol and conditions exacerbated by its use. Screening, using an
evidence-based assessment tool such as the SMAST-G, is the first step in
the Substance Abuse and Mental Health Services Administration
(SAMHSA) Screening, Brief Intervention, Referral to Treatment (SBRIT)
process (SAMHSA, 2017).
Alcoholism treatment programs designed specifically for older adults
are rare, and it is likely that traditional program staff are unfamiliar with the
unique characteristics and needs of the older alcoholics. Gerontological
nurses must ensure that the needs of the older alcoholics are competently
addressed. For example, benzodiazepines, commonly used for
detoxification, can cause toxicity in older people at the same dosage levels
that are prescribed for younger adults. Dosage adjustments are necessary, as
is close monitoring for complications.
Alcoholics Anonymous (see the Online Resources at the end of the
chapter) is a free program for recovery, available in most communities,
which provides counseling and opportunities for alcohol-free socialization
for the older alcoholics. Supplying patients with locations, meeting times,
and encouragement to attend meetings can be significant to helping them
get on the treatment path.
CONSIDER THIS CASE

Seventy-nine-year-old Mrs. B has recently
moved into an in-law apartment in the home of her son and daughter-in-
law. She shares meals and social time with her son and daughter-in-law
but otherwise lives independently in her apartment. During the day, Mrs. B
entertains friends who share alcoholic beverages with her. By the time her
son and daughter-in-law come home from work in the evening, Mrs. B is
intoxicated. Although she is able to walk and engage in most normal
activities, her speech is slurred and her gait unsteady. There have been
occasions when she forgot something was on the stove, setting off the fire
alarm, and left doors open and unlocked when she left the house.
THINK CRITICALLY
1. What risks does Mrs. B impose for herself and her family?
2. What approaches can the family use to address the problem

with Mrs. B?
3. What resources may be of help?
Paranoia
Paranoid states occur in older adults for multiple reasons, such as the
following:
Sensory losses, common in later life, may cause the environment to be

misperceived.
Illness, disability, living alone, and a limited budget promote
insecurity.
Ageism within society sends a negative message about aging.
Older people are victims of crime and unscrupulous practices.
Conditions affecting physical health can contribute to paranoia

especially when chronic conditions become acute. Paranoia can also be an
adverse response to some drugs. This reinforces the importance of a good
physical evaluation and history when psychiatric symptoms present.
The initial consideration in working with paranoid older individuals is
to explore mechanisms that could reduce insecurity and misperception.
Corrective lenses, hearing aids, supplemental income, new housing, and a
stable environment are potential interventions. Psychotherapy and
medications can be used when improvement is not achieved through other
interventions. Nurses should ensure that these patients do not become
withdrawn from the rest of the world because of self-imposed isolation.
Not to be overlooked is the impact of the paranoid state on general
health and well-being. Nutritional status can be threatened if the patient
refuses to eat, believing his or her food to be poisoned; sleep deprivation
can result if there is suspicion that a stranger is in the house; and health
problems may not be diagnosed if the person believes the health care
provider is trying to hurt them. Honest, basic explanations and approaches
to dealing with paranoid misperceptions are beneficial; at no time should
delusions be supported.

MENTAL HEALTH CONDITIONS
Medications used to treat psychiatric disorders can bring significant
improvement to patients, but they can also have profound adverse effects on
older adults. Some of the adverse effects of these medications can lead to
anorexia, constipation, falls, incontinence, anemia, lethargy, sleep
disturbances, and confusion. The lowest possible dosage and frequency
should be used, and any reactions should be observed closely. A checklist
for problem identification, as shown in Table 27-2, may be useful to track
the impact of medications on behavior and function. Of course, drugs
complement and do not substitute for other forms of treatment.
TABLE 27-2 Checklist for Documenting Drugs and Behavior
ADL, activities of daily living.
KEY CONCEPT
Drugs should be viewed as an adjunct to rather than as a substitute for
other forms of treatment.

The importance of promoting a positive self-concept in all older adults is
crucial. All people need to feel that their lives have had meaning and that
there is hope. A sense of meaninglessness and hopelessness threatens
mental health and minimizes the pleasures that the last segment of life can
bring. Nurses should take a sincere interest in the lives and
accomplishments of their older patients. It must be remembered that
disabled or frail people who now present to the nurse may once have
demonstrated the courage to venture from a native country to America,
risked their lives to save fellow soldiers in a war, scrubbed floors at night to
support a family during the Great Depression, or developed a successful
business from scratch. Struggles and accomplishments exist in every life
and can be recognized to help promote self-esteem. Activities such as life-
review discussions, taping oral histories, and compiling a scrapbook of life
events not only help older adults feel a sense of worth about the lives they
have lived but also provide a sense of history and legacy for younger
generations (see Chapter 4). In addition to the past, the present and future
should hold meaning for older adults, and this can be promoted by helping
patients participate in relevant activities, engage in meaningful social
interactions, have opportunities to do for others, exercise the maximum
amount of control possible over their lives, maintain religious and cultural
practices, and be respected as individuals.

Behavioral problems are actions that are annoying, disruptive, harmful, or
generally deviate from the norm and that tend to be recurrent in nature, such
as physical or verbal abuse, resistance to care, repetitive actions, wandering,
restlessness, suspiciousness, and inappropriate sexual behavior and
undressing. These problems can occur in persons with altered cognitive
status who are incapable of thinking rationally and making good judgments
or decisions. Any type of illness that lowers the patient’s ability to cope
with changes and stress can also contribute to these problems. Medications,
environmental factors, a loss of independence, and insufficient activity can
cause problematic behaviors as well.
Assessing the cause of the behavior is the first step in assisting the
patient who displays behavioral problems. Factors associated with the
behavior should be closely observed and documented and include the
following information:
time of onset
where it occurred
environmental conditions
persons present
activities that preceded
pattern of behavior
signs and symptoms present
outcome
measures that helped or worsened the behavior
It is beneficial to correct the underlying cause of the problem whenever

possible. Likewise, factors that precipitate the behavioral problem should be
avoided (e.g., if it is identified that the patient becomes agitated when
seated in a busy hallway, try to seat the patient in a quiet area). Staff or
caregivers can prevent behavioral problems by identifying signs and
symptoms that precipitate the behaviors and intervening in a timely manner.
Environmental considerations that can decrease behavioral problems
include maintaining a room temperature between 70°F (21°C) and 75°F
(24°C), using wall coverings and linens that have simple patterns, limiting
traffic flow, controlling noise, preventing dramatic transitions from daylight
to nighttime darkness, and installing safety devices for monitoring, such as
alarms on doors and video cameras. Table 27-3 reviews some of the major
behavioral problems, their causes, and related nursing interventions.
TABLE 27-3 Understanding and Managing Common

Behavioral Problems
A full discussion of delirium and dementia is provided in Chapter 28.
Using Life Review to Help Depressed Persons with

Dementia
Source: Miyawaki, C. E., Brohard, C., Chen, N., Rubin, A., & Willoughby,
S. (2020). Journal of Gerontological Nursing, 46(2), 41–48. doi:
10.3928/00989134-20200108-04.
Life review therapy has been used as an intervention to help treat
depression among older adults. This study explored the feasibility of
helping caregivers of persons living with dementia to provide life review
therapy to their care recipients. The study used a one-group pre-/poststudy
design and recruited participants from agencies providing community-based
services.
Nineteen family or close friend caregiver–care recipient dyads were
included in the study, though two were withdrawn from the study due to
caregivers not following protocol directions, leaving 17 total dyads
completing the intervention. The caregivers were offered four small group
caregiver training and Caregiver-Provided Life Review (C-PLR)
interventions. Caregiver trainings were conducted via 1-day, 6-hour
sessions to prepare them to conduct live review therapy with their care
recipients. Caregivers conducted weekly life review sessions with their care
recipients at home for 6 weeks. The research assistant checked in with the
caregivers after each life review session and, after the 6-week intervention,
completed posttests and interviews. Study data collected included
demographics, depression measured by the Patient Health Questionnaire-9
(PHQ-9), caregiver burden measured by the 10-item Burden Scale for
Family Caregivers, Short Form, and relationship quality measured by four
questions from the National Study of Caregiving Round 7, Aspects of
Caregiving questions.
Caregiver age ranged from 43 to 74 years (mean 63.6), and most were
female (94%), college-educated (88%), retired (71%), in good health
(47%), and lived with their care recipients (usually their parents). Care
recipient age ranged from 72 to 92 years (mean 83.4), and they were mostly
single (71%), male (53%), and in fair health (53%). The mean (PHQ-9)
scores for care recipients via self-report dropped 2 points from 9.8 pretest to
7.7 posttest (Cohen’s d effect size = 0.35), and the mean (PHQ-9) scores via
caregiver report fell by less than 1 point from 9.4 to 8.6 (Cohen’s d effect
size = 0.15). Mean caregiver burden decreased from pretest to posttest from
16.4 to 15.2 (Cohen’s d effect size = 0.29). The relationship quality
generally remained the same (Cohen’s d effect size = 0.12).
None of the findings were statistically significant, which may have been
due to the small sample size and/or measurement tools used. However, the
authors of this feasibility study concluded that most caregivers were willing
and able to provide the life review therapy for care recipients with mild to
moderate dementia. Future research is warranted.
PRACTICE REALITIES
Mr. Connor has come to the emergency department with chest pain. The
evaluation finds no evidence of cardiovascular disease, and you are
preparing him for discharge. You comment, “I bet it is a relief to hear that
you didn’t have a heart attack.” “I’m not so sure,” he responds. “Sometimes
I think a heart attack would be a great way to put an end to my troubles.”
Concerned, you ask him what he means, and he shares that at 66 years
of age he finds himself still having to work and has little interest or energy
left for anything else. “My kids are grown and barely have time to call me,
my wife is unhappy that I don’t feel like doing anything, and my employer
hints that he could easily replace me with a less expensive younger person.
At this age I thought I’d be retired, travelling, golfing, and enjoying life. I
never expected it to be so hard. Makes you wonder what the point of it all
is.” With that, he prepares to sign his discharge papers and leave.
You see a need and want to help Mr. Connor but are pressured with the
demands of a very busy day in the emergency department. What can you
do?
1. Discuss factors associated with aging in America that contribute
to mental illness in late life.
2. Discuss reasons why alcoholism may be missed in older adults.
3. Describe questions and observations that could be used in an

interview to uncover mental health problems.
4. Describe reasons other than a paranoid disorder for an older adult

being suspicious.
5. As the baby boomers enter older adulthood, what type of mental

health conditions could be more prevalent than with previous
generations of older adults?

questions.
Chapter Summary
Depression is the one of the most frequent mental conditions treated in
older adults. It can be demonstrated in many ways, and its symptoms may
be mistaken as other conditions or assumed to be part of normal aging.
Assessing for depression during routine examinations and when there is a
change in status (e.g., new medical problem, decline in physical function)
can aid in identifying and treating it early.
In addition to suicide being a risk to persons with depression, it is
increasing among healthy older adults who consider it a means to exercise
control over their future and end their lives before experiencing physical
and mental decline. As the baby boomers are demonstrating a high rate of
suicide, their increased presence in the older population could heighten the
number of people for whom suicide is a consideration. Nurses need to
carefully assess for this risk and aid persons with suicidal thoughts or plans
to seek therapy and other forms of support and assistance. Although some
persons enter late life with a history of mental illness, new problems faced
in later years can cause new challenges to mental health and exacerbate
existing mental illness. The promotion of good mental health practices
throughout the life span positively affects mental health in late life and
should be a concern of all nurses.
Anxiety can be demonstrated through increased vital signs and
psychomotor activity, somatic complaints, rigidity in thinking and behavior,
insomnia, fatigue, hostility, restlessness, chain-smoking, pacing,
fantasizing, confusion, and increased dependency. Treatment depends on
the underlying cause. Adequately preparing these individuals for activities
and changes, adhering to familiar routines, and avoiding overstimulation are
among the measures that can be beneficial.
A growing number of people with a history of substance abuse and
active substance use and misuse are entering older adulthood. Nurses
should inquire about drug and alcohol use during the assessment.
Paranoid states in older adults could be reactions to real situations, such
as being victimized by scams or having sensory impairments that lead to
misperceptions of the environment. Consider these potential contributing
factors and implement strategies to minimize or eliminate them to help
decrease paranoia.
Online Resources
Al-Anon Family Group Headquarters (local chapters available)
https://al-anon.org
Alcoholics Anonymous (local chapters available)
https://aa.org http://www.samhsa.gov
Anxiety and Depression Association of America
http://www.adaa.org
Mental Health America
https://www.mhanational.org
Depression and Bipolar Support Alliance
https://www.dbsalliance.org
National Institute on Alcohol Abuse and Alcoholism
http://www.niaaa.nih.gov
Substance Abuse and Mental Health Services Administration
http://www.samhsa.gov
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders:
DSM-5 (5th ed.). Arlington, VA: American Psychiatric Publishing.
Babor, T. F., Higgins-Biddle, J. C., Saunders, J. B., & Monteiro, M. G. (2001). AUDIT: The alcohol
use disorders identification test. Guidelines for use in primary care (2nd ed.). Geneva,
Switzerland: World Health Organization.
Blow, F. C., Brower, K. J., Schulenberg, J. E., Demo- Danaberg, L. M., Young, J. P., & Beresford, T.
P. (1992). The Michigan Alcoholism Screening Test-Geriatric Ver sion: A new elderly-specific
screening instrument. Alcoholism: Clinical and Experimental Research , 16 (2), 372.
Borson, S., Scanlan, J. M., Chen, P., & Ganguli, M. (2003). The Mini-Cog as a screen for dementia:
Validation in a population-based sample. Journal of the American Geriatrics Society , 51 (10),
1451–1454.
Brauser, D. (2015). “Rational suicide” talk increasing among “healthy elderly”. Medscape News.
Retrieved April 8, 2015 from http://www.medscape.com/viewarticle/842819?
nlid=79427_2822&src=wnl_edit_medp_nurs&uac=95177PN&spon=24
Centers for Disease Control and Prevention. (2019). Violence prevention: Suicide risk and protective
factors. Retrieved June 30, 2020 from
https://www.cdc.gov/violenceprevention/suicide/riskprotectivefactors.html
Folstein, M. F., Folstein, S., & McHugh, P. R. (1975). Mini-mental state: A practical method for
grading the cognitive state of patients for the clinician. Journal of Psychiatry Research , 12 ,
189.
McKenzie, G., & Sexson, K. (2021). Late-life depression. In M. Boltz (Executive Ed.), E. Capezuti,
D. Zwicker, & T. Fulmer (Eds.), Evidence-based geriatric nursing protocols for best practice
(6th ed.; pp. 295–316). New York, NY: Springer Publishing Company, LLC.
Nasreddine, Z. S., Phillips, N. A., Bédirian, V., Charbonneau, S., Whitehead, V., Collin, I., …,
Chertkow, H. (2005). The Montreal Cognitive Assessment, MoCA: A brief screening tool for
mild cognitive impairment. Journal of the American Geriatrics Society , 53 (4), 695–699. doi:
10.1111/j.1532-5415.2005.53221.x. Retrieved from https://www.mocatest.org
National Center for Health Statistics. (2018). Suicide rates in the United States continue to increase.
NCHS Data Brief. No. 309. Retrieved June 8, 2020 from
https://www.cdc.gov/nchs/products/databriefs/db309.htm;
https://www.cdc.gov/nchs/data/databriefs/db309.pdf
National Council on Aging. (2018). Fact sheet: Healthy aging. Retrieved June 8, 2010 from
https://d2mkcg26uvg1cz.cloudfront.net/wp-content/uploads/2018-Healthy-Aging-Fact-Sheet-
7.10.18-1.pdf
National Institute on Alcohol Abuse and Alcoholism. Overview of alcohol consumption. Retrieved
June 30, 2020 from https://www.niaaa.nih.gov
Pfeiffer, E. (1975). A short portable mental status questionnaire for the assessment of organic brain
deficit in elderly patients. Journal of the American Geriatrics Society , 23 (10), 433.
Resnick, B. (2019). Geriatric nursing review syllabus: A core curriculum in advanced practice
geriatric nursing (6th ed.). New York, NY: American Geriatrics Society.
Sheikh, J. I., & Yesavage, J. A. (1986). Geriatric Depression Scale (GDS). Recent evidence and
development of a shorter version. In T. L. Brink (Ed.), Clinical gerontology: A guide to
assessment and intervention (pp. 165–173). New York, NY: The Haworth Press, Inc.
Substance Abuse and Mental Health Services Administration. (2017). Screening, Brief Intervention,
and Referral to Treatment (SBIRT). Retrieved June 11, 2020 from https://www.samhsa.gov/sbirt
Tariq, S. H., Tumosa, N., Chibnall, J. T., Perry, H. M., III, & Morley, J. E. (2006). The Saint Louis
Mental Status (SLUMS) Examination for detecting mild cognitive impairment and dementia is
more sensitive than the Mini-Mental Status Examination (MMSE)—A pilot study. American
Journal of Geriatric Psychiatry , 14 , 900–910.
Yesavage, J. A., Brink, T. L., Rose, T. L., Lum, O., Huang, V., Adey, M. B., & Leirer, V. O. (1983).
Development and validation of a geriatric depression screening scale: A preliminary report.
Journal of Psychiatric Research , 17 , 37–49.
Zung, W. W. (1965). A self-rating depression scale. Archives of General Psychiatry , 12 , 63.
A 58-year-old male wearing a face mask presents at the local emergency
department.
Nurse’s
Notes
1215: The client reports, “My heart is beating really, really hard, and it’s
hard to catch my breath.” The client’s spouse shares that “George has
been so worried about the coronavirus epidemic. He is so concerned
about all of us getting sick, especially his 84-year-old mother.” The client
asks, “Am I having a heart attack? I’m very afraid it could be the
coronavirus.”
CHAPTER 28
Delirium and Dementia
Chapter Outline
Delirium
Dementia
Other Dementias
LEARNING OBJECTIVES
1. Differentiate delirium from dementia.

2. Identify factors that cause delirium in older adults.
3. Describe the characteristics, symptoms, and management of
4. List causes of dementia in older adults other than Alzheimer’s disease.
5. Outline nursing considerations for the older adult with dementia.
TERMS TO KNOW
Deliriumacute confusion, usually reversible
Dementiairreversible, progressive impairment in cognitive function
Mild cognitive impairmenttransitional stage between normal cognitive
aging and dementia in which the person has short-term memory
impairment and challenges with complex cognitive functions
Sundowner syndromenocturnal confusion
Impaired cognition affects the ability to communicate, function

independently, make decisions, and comprehend events. With advancing
years, there is increased risk of both delirium , the reversible alteration in
cognition caused by acute conditions, and dementia , the irreversible
impairment in cognition caused by disease or injury to the brain. Although
both conditions cause cognitive impairment, there are significant
differences (Table 28-1). Assisting with the prevention, diagnosis, and
treatment of dementia and delirium is an important responsibility of the
gerontological nurse. Assessment and acting upon findings related to
mentation is also part of the 4Ms Framework (What Matters, Medication,
Mentation, Mobility) in the Age-Friendly Health System’s Model of Care
shown in Figure 21-4 and discussed in Chapter 21 ( Institute for Healthcare
Improvement, 2019 ).
TABLE 28-1 Delirium Versus Dementia

DELIRIUM
Delirium is an acute change in mental status that may signify a medical
emergency. Early detection and treatment are crucial to patient outcomes.
Delirium is common in acute and emergent care settings. Delirium
incidence is approximately 33% among general medical patients aged 70
and over, either present on admission or developed during the
hospitalization (Inouye, Westendorp, & Saczynski, 2014; Marcantonio,
2017). Delirium incidence in the emergency department is 10% to 15%, and
postsurgery it is 15% to 25% for elective surgery and 50% for higher-risk
procedures such as hip replacement and cardiac surgery (Marcantonio,
2017). Delirium may also reach 85% at the end of life in palliative care
settings (Marcantonio, 2017).
A variety of conditions can impair cerebral circulation and cause
disturbances in cognitive function (Box 28-1). Sometimes the history,
physical examination, or laboratory tests will indicate the presence of a
specific cause of the cognitive disturbance; however, without such
evidence, the diagnosis of delirium can be established by the symptoms and
lack of any other signs of mental health disorders.
BOX 28-1 Potential Causes of Delirium

Fluid and electrolyte imbalances
Medications
Congestive heart failure
Hyperglycemia and hypoglycemia
Hyperthermia and hypothermia
Hypercalcemia and hypocalcemia
Hypothyroidism
Decreased cardiac function
Decreased respiratory function
Decreased renal function
Central nervous system disturbances
Emotional stress
Pain
Malnutrition
Dehydration
Anemias
Infection
Hypotension
Trauma
Malignancy
Alcoholism
Hypoxia
Toxic substances
The onset of symptoms with delirium tends to be rapid and may include
acute change in mental status and fluctuation course throughout the day,
inattention, disturbed intellectual function, and disorganized thinking;
disorientation of time and place but usually not of identity; altered attention
span; worsened memory; labile mood; meaningless chatter; poor judgment;
and altered level of consciousness, including hypervigilance, mild
drowsiness, and semicomatose status. Significant perceptual changes can
occur, such as hallucinations (usually visual) and illusions (e.g.,
misinterpreting caregivers as police guards). Disturbances in sleep–wake
cycles can occur; in fact, restlessness and sleep disturbances may be early
clues. The patient may be suspicious, have personality changes, and
experience illusions more often than delusions. Physical signs, such as
shortness of breath, fatigue, and slower psychomotor activities, may
accompany behavioral changes.
KEY CONCEPT
Delirium may signify a medical emergency, whereas dementia does not.
Early identification and treatment of delirium is crucial to recovery and
prevention of hospital admission or readmission.
Nurses need to play a significant role by identifying signs of confusion

promptly. A good history and assessment of mental status on initial contact
can provide the baseline data with which changes can be compared (see
Assessment Guide 27-1 in Chapter 27). Any change in behavior or
cognitive pattern warrants evaluation comprehensive assessment. There is
the risk that delirium may not be recognized if persons unfamiliar with the
patient assume that poor or altered cognition is normal for him or her.
Likewise, persons with dementia can develop delirium superimposed on the
dementia. This may be as a response to an acute condition but be
undiagnosed because changes are not understood or identified.
Delirium is reversible in most circumstances, and prompt care, treating
this condition as a medical emergency, can prevent permanent damage.
Treatment depends on the cause (e.g., stabilizing blood glucose, correcting
dehydration, correcting electrolyte imbalances, and addressing
polypharmacy, treating an infection). Treating the symptoms rather than the
cause or accepting the symptoms as normal and failing to obtain treatment
may result in worsened mental status due to the continuation of an acute
condition that could be life threatening.
KEY CONCEPT
As older adults often have multiple health conditions, it is important to
remember that several coexisting factors can cause delirium.
Establishing medical stability and minimizing stimulation are primary

goals. Consistency in care is important; thus, the patient benefits from
interaction with only a limited number of people. Providing frequent
orientation and explanations fosters function and reduces anxiety and stress.
Controlling environmental temperature, noise, and traffic flow is important.
Placing this patient in a quiet area away from the mainstream activity is
beneficial. Bright lights should be avoided, but ample lighting is needed to
enable the patient to adequately visualize the environment. The nurse
should ensure that patients do not harm themselves or others and that
physical care needs are met.
Families may need considerable support and realistic explanations to
alleviate their anxieties. (For example, the nurse may state, “No, he does
not have Alzheimer’s disease. His confusion occurred because the level of
glucose, or sugar, in his blood dropped too low. He’ll improve as the sugar
level is brought back to normal.”)If the person becomes agitated or
combative during the communication, remain calm and relaxed. If the
patient is in an area with other people, attempt to guide the patient to a
quieter area. Use gentle touch (e.g., stroking the arm) unless the person
appears threatened or agitated by the contact. If the patient becomes
combative, keep a safe distance between you and the patient. Avoid asking
questions or arguing, and offer simple, reassuring comments. Try to divert
the patient’s attention (e.g., pointing out a new card that the patient received
or a picture on the wall).Any information the nurse gleans concerning
factors that trigger agitation for this patient and measures that can facilitate
communication with the patient should be documented in the patient’s
record and shared with others who have contact with the patient.
COMMUNICATION TIP
Regardless of the patient’s level of intellectual function or
consciousness, it is important to speak to the patient and offer
explanations of activities or procedures being done. Approach from
the front, make eye contact, talk slowly, and speak in a calm manner.
While keeping explanations and questions simple, it is important to
address the person as an adult and be aware when the person is present
while discussing the patient with others in the room. Avoid rushing
and overwhelming the patient.
DEMENTIA
Dementia is a progressive, irreversible impairment in cognitive function
affecting memory, orientation, judgment, reasoning, attention, language,
and problem-solving. It is caused by damage or injury to the brain. An
estimated 5% older adults suffer some form of dementia.
Alzheimer’s disease is the most common form of dementia, accounting for
60% to 80% of all dementias. Approximately 80% of those living with
Alzheimer’s dementia are aged 75 and over (Alzheimer’s Association,
2020), and about 10% of older adults aged 65 and over have Alzheimer’s
dementia. Almost two thirds of Americans with Alzheimer’s disease are
women. Older African Americans are about twice as likely to have
Alzheimer’s or other dementias compared to older Whites. Hispanics are
about one and a half times as likely to have Alzheimer’s or other dementias
compared to older Whites (Alzheimer’s Association, 2020).
Alzheimer’s disease is characterized by two changes in the brain. The
first is the presence of neuritic plaques, which contain deposits of β-
amyloid protein (excess amounts of this are found in persons with
Alzheimer’s disease and Down’s syndrome). β-Amyloid protein is a
fragment of amyloid precursor protein that helps the neurons grow and
repair. The β-amyloid fragments clump together into plaques that impair the
function of nerve cells in the brain. It is unclear at this point if the plaques
are a cause or by-product of the disease.
The second characteristic brain change is neurofibrillary tangles in the
cortex. Microtubules, structures within healthy neurons, are normally
stabilized by a special protein called tau. In Alzheimer’s disease, tau is
changed and begins to pair with other threads of tau that become tangled.
This causes the microtubules to disintegrate and collapse the neuron’s
transport system.
These brain changes lead to a loss or degeneration of neurons and
synapses, especially within the neocortex and hippocampus. Interestingly,
the cause-and-effect relationship between these brain changes and
Alzheimer’s disease is unclear at present.
There are also changes in neurotransmitter systems associated with
Alzheimer’s disease, including reductions in serotonin receptors, serotonin
uptake into platelets, production of acetylcholine in the areas of the brain in
which plaque and tangles are found, acetylcholinesterase (which breaks
down acetylcholine), and choline acetyltransferase. (Cholinesterase
inhibitors and nicotinic, muscarinic, and cholinergic agonists are among the
neurotransmitter-affecting drugs used in the treatment of Alzheimer’s to
compensate for the neurotransmitter changes.)
Recent studies have confirmed that there are pathological changes in the
brain years before symptoms of Alzheimer’s disease appear. The
transitional stage between normal cognitive aging and dementia in which
the person has short-term memory impairment and challenges with complex
cognitive functions is referred to as mild cognitive impairment . Persons
with mild cognitive impairment have a higher risk of developing
Possible Causes
Although environmental factors play a role, genetic factors do increase the
risk of Alzheimer’s disease. Studies have revealed several generations of
Alzheimer’s disease patients occurring in the same family. Chromosomal
abnormalities have been identified. A strong argument for the genetic
formulation of the disease stems from its connection with Down’s
syndrome. An extra chromosome 21 exists in persons with Down’s
syndrome; not only do people with Down’s syndrome begin to develop
symptoms of dementia after age 35 but also the prevalence of Alzheimer’s
disease is higher in families with Down’s syndrome, and vice versa
(Alzheimer’s Association 2020; National Institute on Aging, 2019). An
altered chromosome 21 in people with Alzheimer’s disease causes
production of an abnormal amyloid precursor protein. Chromosomes 14 and
1 have also been found to have mutations within families who have a high
prevalence of Alzheimer’s disease; these mutations cause abnormal proteins
to be produced. Monitor assessment of intellectual, behavioral, and social
function over time. For those unable to provide detailed history, engage
family members or other caregivers for information.
POINT TO PONDER
Would you want to know if you had a genetic predisposition toward
Alzheimer’s disease? What difference could this make in your life?
There is some investigation into the role of free radicals in the
development of Alzheimer’s disease. Free radicals are molecules that can
build up in neurons, resulting in damage (called oxidative damage). The
damage blocks substances from flowing in and out of the cell, leading to
brain damage. Higher than normal levels of aluminum and mercury have
been found in the brain cells of those living with Alzheimer’s disease,
causing some speculation regarding the role of environmental toxins in the
disease. However, the results are inconclusive as to their role in the
development of Alzheimer’s disease. Low zinc levels may be present in
persons with Alzheimer’s disease, although it is not certain if this is a cause
or result of the disease.
There has been some speculation about a slow-acting virus causing the
neurofibrillary tangles in the brain, but no conclusive evidence exists at
present to support this theory. Some risks hypothesized to be associated
with Alzheimer’s disease include hyperlipidemia, hypertension, smoking,
head injury, and physical and mental inactivity. At present, no one theory
can explain this complex disease.
Symptoms
The symptoms of this progressive, degenerative disease develop gradually
and progress at different rates among affected individuals. The Global
Deterioration Scale/Functional Assessment Staging Test (FAST) offers a
means of staging Alzheimer’s disease (Fig. 28-1) (Auer & Reisberg, 1997;
Reisberg, 1988, 2005). Although staging of the disease can help predict its
general course and anticipate plans for care, it must be appreciated that
many factors affect the progression of the disease and that there will be
individual variation.
FIGURE 28-1 Stages of Alzheimer’s disease (AD).
IADL, instrumental activities of daily living; ADL,
activities of daily living. (Source: Reisberg, B., Ferris, S.
H., de Leon, M. J., & Crook, T. (1982). The Global
Deterioration Scale for assessment of primary dementia.
American Journal of Psychiatry , 139 , 1136–1139; Auer,
S., & Reisberg, B. (1997). The GDS/FAST staging system.
International Psychogeriatrics , 9 (Suppl. 1), 167–171.)
Early in the disease, the patient may be aware of changes in intellectual

ability and become depressed or anxious or attempt to compensate by
writing down information, structuring routines, and simplifying
responsibilities. It may take some time for symptoms to be detected, even
by those close to the patient.
KEY CONCEPT
The greatest risk of suicide for a person with dementia is in the early
stage of the disease when the individual is aware of the changes
experienced.
In addition to the history of symptoms from the patient, family

members, caregivers, or significant others, diagnosis is aided by brain scans
that can reveal changes in the brain’s structure that are consistent with the
disease, neuropsychological testing that evaluates cognitive functioning,
and laboratory tests and neurological examinations.
Researchers recently have reported that there is a variant of Alzheimer’s
disease called hippocampal-sparing AD that often is misdiagnosed as other
conditions due to different symptomatology (Murray et al., 2014). They
found that upon autopsy, of the 11% of the brains that were examined and
confirmed to be Alzheimer’s disease, half of the individuals were
misdiagnosed. Persons with hippocampal-sparing AD had normal memories
but experienced other symptoms, such as language disturbances, angry
outbursts, visual disturbances, and feelings that they couldn’t control their
limbs. Due to the symptoms, these individuals often were misdiagnosed as
having frontotemporal dementia or corticobasal syndrome. Hippocampal-
sparing AD tends to affect men more than women and occur at a younger
age. Also, the condition progresses more rapidly than does typical
Alzheimer’s disease. More research is needed in this area.
Treatment
Although currently there is no treatment to prevent or cure Alzheimer’s
disease, clinical trials are being conducted by the National Institutes of
Health and private industry in hopes of finding a means to improve function
and slow the progress of the disease. There has been interest in estrogen’s
role in enhancing cognitive function, with speculation that estrogen has a
role in protecting postmenopausal women from developing Alzheimer’s
disease or other age-related cognitive decline; however, research has
produced conflicting results as the women’s Health Initiative Memory
Study demonstrated an increased risk of dementia in postmenopausal
women in women taking estrogen with progestin (Barron & Pike, 2012).
Antioxidants, anti-inflammatory agents, supplements (folic acid and
vitamins B6 and B12), gene therapy that adds a nerve growth factor to the
aging brain, and the development of a vaccine are among the other areas
being investigated in clinical trials (Université Laval, 2013).
Because acetylcholine falls sharply in people with Alzheimer’s disease,
medications that stop or slow the enzyme (acetylcholinesterase) that breaks
down acetylcholine have been developed to help people with Alzheimer’s
disease; these drugs include donepezil (Aricept), rivastigmine (Exelon), and
galantamine (Reminyl; Razadyne) for mild to moderate Alzheimer’s and
memantine (Namenda), Exelon patch, and Namzaric (combination of
memantine and donezepil) for moderate to severe Alzheimer’s (National
Institute on Aging, 2019).
KEY CONCEPT
Other diseases can mimic Alzheimer’s disease; therefore, a
comprehensive assessment is essential to rule out other possible causes
of dementia or cognitive loss before the diagnosis of Alzheimer’s disease
is made.
Other Dementias
In addition to Alzheimer’s disease, a variety of other pathologies can cause
dementia:
Vascular dementia results from small cerebral infarctions. Damage to

the brain tissue can be diffuse or localized, the onset is more rapid, and
the disease progresses more predictably than Alzheimer’s disease. It is
associated with risk factors such as smoking, hypertension,
hyperlipidemia, inactivity, and a history of stroke and/or
cardiovascular disease.
Frontotemporal dementia is characterized by neuronal atrophy
affecting the frontal lobes of the brain rather than by neurofibrillary
tangles and plaques as in Alzheimer’s disease. A unique characteristic
of this dementia is the appearance of behavioral rather than cognitive
abnormalities in the early stage. Also, rather than poor memory, early
cognitive changes can include apathy and impairments in abstract
thinking and speech and language skills.
Lewy body dementia, also known as cortical Lewy body disease, is
associated with subcortical pathology and the presence of Lewy body
substance in the cerebral cortex. People with this dementia have
fluctuations in mental status, decompensate rapidly when they
experience a medical condition, and often have idiosyncratic reactions
to cholinergic-type medications (e.g., sedatives and antipsychotics).
About one fourth of the people diagnosed with this dementia have a
history of a family member with dementia. Lewy body dementia is
often misdiagnosed as other forms of dementia.
Creutzfeldt-Jakob disease is an extremely rare brain disorder that
causes dementia. It has a rapid onset and progression and is
characterized by severe neurological impairment that accompanies the
dementia. It is believed that this disease can be transmitted through a
slow virus; a familial tendency toward the disease is possible. The
pathological process displays destruction of neurons in the cerebral
cortex, overgrowth of glia, abnormal cellular structure of the cortex,
hypertrophy and proliferation of astrocytes, and a spongelike
appearance of the cerebral cortex. Symptoms are more varied than
with Alzheimer’s disease and include psychotic behavior, heightened
emotional lability, memory impairment, loss of muscular function,
muscle spasms, seizures, and visual disturbances. The disease
progresses rapidly, and death typically occurs within 1 year of
diagnosis:
Wernicke’s encephalopathy and Parkinson’s disease are responsible for
a small percentage of dementias.
AIDS may lead to the development of dementia in the final phase of
the disease.
Trauma and toxins are among the other causes of dementia.
These other forms of dementia can present with symptoms similar to

those commonly associated with Alzheimer’s disease. Hence, a
comprehensive assessment is needed to identify or exclude other causes of
dementia.

Creutzfeldt-Jakob disease is an extremely rare disorder and causes
dementia, not delirium.
Unfolding Patient Stories: Millie Larsen • Part 2
Recall from Chapter 4 Millie Larsen, an 84-

year-old who lives alone. While visiting her at home recently, Millie’s
daughter, Dina, notices she is acting strangely and not making sense.
Millie is admitted to the hospital with the diagnosis of a urinary tract
infection and dehydration. The daughter tells the nurse, “I’m worried that
my mom may have dementia because she is more forgetful and appears
confused.” How would the nurse explain to the daughter the difference
between the clinical manifestations of delirium and dementia? How would
the nurse address the daughter’s concern? How would the nurse facilitate
an interprofessional approach to addressing Millie’s symptoms?
Care for Millie and other patients in a realistic virtual environment:
(thepoint.lww.com/vSimGerontology). Practice documenting
these patients’ care in DocuCare (thepoint.lww.com/DocuCareEHR).
The irreversible nature of dementia and its progressive deteriorating course
can have devastating effects on affected individuals and their families. A
majority of the care required by persons with dementia falls within the
scope of nursing practice.
Ensuring Patient Safety

One of the foremost care considerations is the safety of patients with
dementia. Their poor judgment and misperceptions can lead to serious
behavioral problems and mishaps. A safe, structured environment is
essential. The persons and components of the environment should be
consistent (Fig. 28-2). Items to trigger memory are useful to include, such
as photographs of the patient or a consistently used symbol (e.g., flower or
triangle) on the bedroom door or personal possessions. Noise, activity, and
lighting levels can overstimulate the patient and further decrease function;
thus, they need to be controlled. This is particularly useful in preventing
and managing sundowner syndrome (Box 28-2).
FIGURE 28-2 Familiar objects, a stable environment, and
consistency of caregivers can reduce some of the safety
risks and behavioral problems associated with dementias.
BOX 28-2 Sundowner Syndrome

Individuals with cognitive impairments may experience a nocturnal
confusion, named sundowner syndrome due to its presentation “as the
sun goes down.” Some of the factors that increase the risk of this
condition include unfamiliar environment (e.g., recent admission to a
facility), disturbed sleep patterns (e.g., from sleep apnea), use of physical
restraints, sensory overload, sensory deprivation, or change in circadian
rhythms.
Nurses can prevent and manage sundowner syndrome by
placing familiar objects and photos in the person’s room

providing physical activity opportunities in the afternoon to help the
person expend energy
adjusting lighting to prevent the room from becoming dark in the
evening
keeping a night-light on throughout the night
having frequent contact with the person to offer reassurance and
orientation
using touch to provide human contact and calm the person
ensuring the environmental temperature is within a comfortable
range for the person
controlling noise and traffic flow in the evening
ensuring the person’s basic needs are met (e.g., adequate food and
fluids, toileting, and dry clothing)
Cleaning solutions, pesticides, medications, and inedible items that

could be ingested accidentally must be removed, placed out of sight, or
stored in locked cabinets. Coverings should be applied to unused sockets,
electrical outlets, fans, motors, and other items into which fingers may be
poked. Matches and lighters should not be accessible; if the patient smokes,
it must be under close supervision. Oven and stove knobs should be
removed to avoid accidentally leaving these appliances on. Windows and
doors can be protected with Plexiglas, and nonremovable screens can be
installed to avoid falls from windows. Wandering is common among
patients with dementia; rather than restrain or restrict them, it is more
advantageous to provide a safe area in which they can wander. Protective
gates can be installed to prevent patients from wandering; alarms and bells
on doors can signal when they are attempting to exit. With the great risk of
patients wandering and not being able to give their names or residence
when found, it is beneficial for them to wear identification bracelets at all
times and to have a recent photograph available. Suggest a local “safe
return” program such as the Alzheimer’s Association Safe Return Program
that provides 24 hours/7 days per week wandering support.
The prevention of abuse is another safety consideration. Those with
dementia are at increased risk of elder mistreatment due to poor cognitive
function. Older adults with dementia may be mistreated by caregivers who
become stressed by increased care needs and/or behavioral or psychological
symptoms of dementia of the affected individuals. It is important to assess
how well caregivers are managing and coping with the persons they care for
and to provide support and assistance to prevent them from becoming
overwhelmed. Respite care may be beneficial for caregivers exhibiting
caregiver stress or burden.
Promoting Therapy and Activity

Various therapies and activities can be offered to the patient with dementia,
depending on the patient’s level of function. Occupational, physical, and
recreation therapies may benefit those with early dementia, depending on
the need. Various degrees of reality orientation, ranging from daily groups
to reminding the patient who the patient is during every interaction, can be
used. Those living with dementia continue to benefit from continued
stimulation and derive pleasure through activities, such as listening to
music, petting an animal, and touching various objects.
Modified communication techniques can facilitate activity. Suggested
strategies include the following:
Use simple sentences that contain only one idea or instruction.
Speak in a calm manner using an adult tone (not baby talk or
elderspeak).
Avoid words or phrases that may be misinterpreted or sarcasm.
Offer opportunities for simple decisions.
Avoid arguments.
Provide distractions from conflict, difficult situations, or negative
experiences.
Recognize efforts with positive feedback.
Observe nonverbal expressions and behaviors, and act on any needs.
Providing Physical Care

The physical care needs of patients with dementia must be addressed.
Individuals living with dementia may not complain that they are hungry, so
no one may notice that they have consumed less than one quarter of the
food served; they may not remember to drink water, so they can become
dehydrated; they may fight their bath so strongly that they are left unbathed;
and pressure injuries on buttocks may go unnoticed. These individuals need
close observation and careful attention to their physical needs. Nurses and
other health care providers should anticipate physical and social needs of
older adults with dementia. Consideration must be given to a potential
inability to communicate needs such as pain, or any discomfort, or the need
to use the bathroom. Observe for subtle changes in behavior or function, a
facial grimace, or repeated touching of a body part, which may provide
evidence that a problem exists. Consistency in caregivers allows the
caregivers to become familiar with a patient’s unique behaviors and more
quickly recognize a deviation from that individual’s baseline.

A variety of alternative medical therapies are being used to treat dementias.
Nutritional supplements that have been used include vitamins B6, B12, C,
and E; folic acid; zinc; and selenium. The herb Ginkgo biloba has been
shown to improve circulation and mental function in several clinical trials
(Dos Santos-Neto, de Vilhena Toledo, Medeiros-Souza, & de Souza, 2006;
Rassamy, Longpre, & Christen, 2007); caution is needed, however, because
Ginkgo biloba can increase the risk of intraocular hemorrhage and subdural
hematoma when taken for an extended period of time or when an
anticoagulant drug is being taken concurrently. Chinese medicine, in
addition to herbs and nutrition, uses a form of therapeutic exercise called
qigong; it is believed that oxygenation to the brain improves by the
breathing exercises and visualization used in qigong exercises.
Respecting the Individual

As dementia progresses, a person’s dignity, personal worth, freedom, and
individuality may be negatively affected. Loved ones may view the person
with dementia as a stranger living inside the body that once housed the
person they knew. Staff may see another dependent or total-care patient and
have no sense of that person’s unique life history. Special attention must be
paid to maintaining and promoting the following qualities:
Individuality. The nurse should learn the personal history and

uniqueness of the patient and incorporate this into caregiving
activities.
Independence. Nurses should give the patient time and opportunity for
self-care.
Freedom. Nurses should allow the patient as much control and choice
as possible, keeping in mind safety, to promote freedom of activities
Dignity. Nurses should respect and help maintain a person’s dignity.
This includes using the person’s given name and providing appropriate
clothing grooming, adult hairstyles, privacy, and confidentiality.
Connection. Persons with dementia continue to be valued human
beings who are members of families, communities, and the universe.
Interaction and connection with other people and nature show
recognition and respect for the spiritual beings that live within the
bodies and minds of those with dementia or altered cognition.
Supporting the Patient’s Family

Assistance and support to the families of patients are integral parts of
nursing care for persons with dementia. The physical, emotional, and
socioeconomic burden of caring for a relative with cognitive impairment
can be overwhelming, especially with competing responsibilities such as
work and other family caregiving responsibilities. Do not assume that
family members understand basic care techniques. The nurse needs to
review basic, specific care techniques, including lifting, bathing, and
managing behavioral and psychological problems. The nurse can also help
prepare families for any guilt, frustration, anger, depression, stress, and
other feelings that may accompany caregiving responsibility. Helping
families plan respite, network with support groups, and obtain counseling
may be beneficial. Most states have chapters of the Alzheimer’s
Association to which nurses can refer families (see Online Resources
listing). Local area senior centers, hospitals, and adult day care facilities
may have support groups and respite programs as well.
KEY CONCEPT
Nurses need to ensure that family members understand basic caregiving
skills, such as techniques for feeding, bathing, and lifting.
NURSING CARE PLAN 28-1 describes a care plan for a person with

THE OLDER ADULT WITH ALZHEIMER’S DISEASE
Nursing Problem: Difficulty with self-feeding due to dementia and/or
delirium
Nursing Problem: Difficulty with toileting and/or maintaining
continence due to dementia and/or delirium
Nursing Problem: Potential for injury due to wandering, poor

judgment, or poor insight due to dementia and/or delirium
Nursing Problem: Sleeping difficulty due to dementia and/or delirium
Nursing Problem: Difficulty with verbal and nonverbal communication

due to dementia and/or delirium
Nursing Problem: Family or caregiver stress
CONSIDER THIS CASE
A home health nurse is making an initial

home visit to evaluate 69-year-old Mr. S, who has Alzheimer’s disease,
and to assist his wife in developing effective caregiving plans. Mr. S was
diagnosed approximately 1 year earlier as a result of an evaluation
initiated by the university where he taught. University sources stated that
Mr. S was behaving inappropriately: entering other professors’ classrooms
and beginning to lecture, having unexplained absences for classes and
meetings, showing up to work with the same clothes for days, addressing
his class in an incoherent manner, and asking coworkers for assistance in
operating office equipment that he had used for years without difficulty.
After observing Mr. S’s condition progressively worsen over time, the
dean of the university telephoned Mrs. S to discuss the situation. Mrs. S
claims that she noticed that her husband was acting unusual (forgetting
names and appointments, bouncing checks, arguing for no reason, making
unkind comments to friends, and confusing days off with workdays) but
thought this could be related to “getting older” and job stress. When the
dean spoke with her, Mrs. S realized that a serious problem might exist
and accompanied her husband for an evaluation, the result of which was
the establishment of a diagnosis of Alzheimer’s disease.
Mr. S retired immediately from the university and has been cared for
by his wife consistently each day since. Mrs. S offered no complaints until
this past month, when she repeatedly called the physician to discuss the
new problems that Mr. S was exhibiting, including urinary incontinence,
eating difficulties, and wandering. These new problems have devastated
Mrs. S; she looks fatigued and claims to be eating and sleeping poorly. She
firmly states that she “will never consider placing her husband in an
institution” and that she’ll take care of him at home even “if it kills her.”
THINK CRITICALLY
1. What needs do both Mr. and Mrs. S have at this time?
2. What resources could be helpful to Mrs. S to assist her in

coping with the demands of caregiving?
Social Support and High Resilient Coping in

Carers of People With Dementia
Source: Jones, S. M., Woodward, M., & Mioshi, E. (2019). Geriatric
Nursing, 40(6), 584–589.
Informal carers provide much of the support to older adults with
dementia in the community. This cross-sectional study conducted in the
United Kingdom compared sociodemographic characteristics and
availability of social support of carers of people with dementia. Measures
used included sociodemographic variables (age, gender, education level,
employment status, relationship to the person living with dementia, and
whether the carer lived with the person with dementia), resilience using The
Brief Resilient Coping Scale, social support using The Medical Outcomes
Study Social Support Survey, and level of independence of the person with
dementia using The Bristol Activities of Daily Living Scale.
There were 108 carers as study participants, the majority of which were
female (69%) and aged 70 and above (72%). Most carer study participants
were spouses (61%) and lived with the person with dementia (78%). The
carer study participants were split into low or high resilient coping groups
based on the Brief Resilient Coping Scale scores. Those with low resilient
coping scores reported lower scores on all domains of social support
(emotional/informational support, tangible support, affection, and social
interaction).
Study findings showed that each domain of social support had a
positive relationship with high resilient coping. Carers with high resilient
coping skills perceived they had greater access to all forms of social support
compared to those with low resilient coping skills. Only gender predicted
high resilient coping, with females scoring highest. No one domain of social
support predicted high resilient coping. The availability of
emotional/informational support was most likely to predict resilient coping
and tangible support the least likely. Researchers suggest that service
providers enable carers to build a wide, multifunction support network.
Nurses are in an excellent position to work with interprofessional team
members to help link carers to support networks in the community.
PRACTICE REALITIES
You accept a position at a large nursing home that has a “Special Care Unit”
for persons with dementia. There are 25 residents on the unit with moderate
to advanced dementia. You notice that the unit looks like all the other units,
so during your orientation you ask about the programs and features that
make the unit unique. You are told that the Activities Department does a
group activity at 2 pm every afternoon and that to prevent wandering off the
unit, the doors require punching in a special code to exit.
As the days progress, you determine that there is actually nothing
unique about this unit. Residents spend most of their day sitting in the
hallway or dining room, and staff spend most of their time behind the
nursing station. You mention to your supervisor that you think there are
some interventions that could be used and changes implemented that could
provide a higher quality of life and services for the residents. The
supervisor encourages you to offer ideas.
What are the environmental changes and programming that could
support effective care of residents with dementia on this unit? How could
you implement them?

1. Describe situations that an older patient could experience during
a hospitalization for surgery that could cause delirium.
2. Discuss the impact of an older person’s diagnosis of Alzheimer’s

disease on the spouse, adult children, and grandchildren.
3. In what ways could a person show denial of a spouse’s signs of

dementia? What behaviors by the well spouse could delay the
diagnosis of the affected spouse?
4. What risks would an older adult with a mild dementia face if he

or she lived alone in the community?

questions.
A home health nurse is making an initial home visit to evaluate 69-year-

old Mr. Downey and to assist his spouse in developing effective
caregiving plans.
Nurse’s Notes
1400: Mr. Downey was diagnosed with Alzheimer’s disease several
months ago. The client has since retired, and Mr. Alvera, the client’s
spouse, identified no specific problems until this past month, when he
repeatedly called the primary healthcare provider to discuss the new
symptoms exhibited by his husband. These included urinary
incontinence, eating difficulties, and Mr. Downey’s tendency to wander
away from their home both during the day and at night.
Chapter Summary
Delirium may be caused by anything that disrupts the body’s homeostasis
and impairs cerebral circulation. Delirium is mainly an acute change in
mental status causing changes in cognition and attention. Cognitive and
perceptual changes can occur, as well as alterations in level of
consciousness. There is a risk that signs of delirium older adults may
demonstrate may be mistaken for signs of dementia. It is important to
differentiate delirium from dementia. A comprehensive nursing assessment
and advocacy for individuals with delirium, or delirium superimposed on
dementia, are important. Early identification and treatment of the
underlying cause of delirium can prevent negative consequences and help
the individual return to baseline mental status.
The risk for developing dementia increases with age. Alzheimer’s
disease is the most prevalent type of dementia; other forms of dementia
include vascular dementia, frontotemporal dementia, Lewy body dementia,
Creutzfeldt-Jakob disease, and hippocampal-sparing Alzheimer’s disease.
Wernicke’s encephalopathy, Parkinson’s disease, AIDS, trauma, and toxins
also are responsible for a small number of cases. Regular assessment of the
status of persons with dementia is essential because care needs will change
over time. Also, because the ability of these individuals to accurately
describe and communicate their symptoms can be impaired as their disease
progresses, important nursing measures include close observation and
careful attention to physical, psychological, and social needs. Ensuring
consistency in caregivers will assist in identifying unique expressions and
signs that may demonstrate needs and problems of persons with dementia.
Addressing the needs and problems that occur over the course of the
dementia will help promote dignity and quality of life for the person living
with dementia and help decrease caregiver stress or burden.
Online Resources
Alzheimer’s Association
http://www.alz.org
Alzheimer’s Association Safe Return Program
https://www.alz.org/help-support/caregiving/safety/medicalert-with-24-7-
wandering-support
National Institute on Aging, Alzheimer’s Disease & Related Dementias;
Alzheimer’s and related Dementias Education and Referral Center
https://www.nia.nih.gov/health/alzheimers
National Institute on Aging, Alzheimer’s and Dementia Resources for
Professionals
https://www.nia.nih.gov/health/alzheimers-dementia-resources-for-
professionals
American Delirium Society
https://americandeliriumsociety.org
References
Alzheimer’s Association. (2020). 2020 Alzheimer’s disease facts and figures. Retrieved June 13,
2020 from https://www.alz.org/media/Documents/alzheimers-facts-and-figures.pdf
Auer, S., & Reisberg, B. (1997). The GDS/FAST staging system. International Psychogeriatrics , 9
(Suppl. 1), 167–171.
Barron, A. M., & Pike, C. J. (2012). Sex hormones, aging, and Alzheimer’s disease. Frontiers in
Bioscience Online. Retrieved April 16, 2015 from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3511049/
Dos Santos-Neto, L. L., de Vilhena Toledo, M. A., Medeiros-Souza, P., & de Souza, G. A. (2006).
The use of herbal medicine in Alzheimer’s disease—A systematic review. Evidence-Based
Complementary and Alternative Medicine , 3 (4), 441–445.
Inouye, S. K., Westendorp, R. G., & Saczynski, J. S. (2014). Delirium in elderly people. The Lancet ,
383 , 911–922. doi: 10.1016/S0140-6736(13)60688-1.
Institute for Healthcare Improvement. (2019). Age-friendly health systems: Guide to using the 4Ms in
the care of older adults . Massachusetts: Institute for Healthcare Improvement.
Marcantonio, E. R. (2017). Delirium in hospitalized older adults. New England Journal of Medicine ,
377 , 1456–1466. doi: 10.1056/NEJMcp1605501.
Murray, M., Duara, R., Liesinger, A., Ross, O., Petersen, R., et al. (2014). Focal cortical patterns in
hippocampal sparing AD reveal significant clinical differences. Retrieved June 14, 2020 from
http://www.neurology.org/content/82/10_Supplement/S48.001
National Institute on Aging. (2019). Alzheimer’s disease fact sheet. Retrieved June 14, 2020 from
https://www.nia.nih.gov/health/alzheimers-disease-fact-sheet
Rassamy, C., Longpre, F., & Christen, Y. (2007). Ginkgo biloba extract (EGb 761) in Alzheimer’s
disease: Is there any evidence? Current Alzheimer Research , 4 (3), 253–262.
Reisberg, G. (1988). Functional Assessment Staging (FAST). Psychopharmacology , 24 (4), 653–
659.
Reisberg, B. (2005). Global Deterioration Scale. Retrieved June 14, 2020 from
http://geriatrictoolkit.missouri.edu/cog/Global-Deterioration-Scale.pdf
Université Laval. (2013). Major step toward an Alzheimer’s vaccine. Science Daily, 15 January
2013. Retrieved June 14, 2020 from
www.sciencedaily.com/releases/2013/01/130115143852.htm
CHAPTER 29
Living in Harmony With Chronic
Conditions
Chapter Outline
Chronic Conditions and Older Adults
Goals for Chronic Care
Assessment of Chronic Care Needs
Maximizing the Benefits of Chronic Care
Factors Affecting the Course of Chronic Care
Chronic Care: A Nursing Challenge
LEARNING OBJECTIVES
1. Discuss the scope of chronic conditions among the older population.

2. Differentiate between healing and curing.
3. List chronic care goals.
4. Outline components of assessment of older adults’ chronic care needs.
5. Discuss approaches to maximize the benefits of conventional
treatments for older adults with chronic conditions.
6. Identify alternative therapies that could benefit older adults with
chronic conditions.
7. Discuss factors affecting the course of chronic care for older adults.
TERMS TO KNOW
Chronic conditionlong-term dysfunction or pathology
Defense mechanismsreactions used to cope with a difficult or stressful
situation
Healingmobilization of body, mind, and spirit to control symptoms,
promote sense of well-being, and achieve highest possible quality of
life
Illness is not an easy situation to accept. Even a common cold disrupts our
lives and makes us uncomfortable, irritable, and unmotivated to work and
play. When sick, the basic activities of daily living can become a chore, our
appearance may be the least of our worries, and our lives may revolve
around the medications, treatments, and doctor’s visits that will make us
feel better. Fortunately, for most people, illness is an unusual and temporary
event; they recover and return to life as usual.
Some illnesses, however, will accompany people for the remainder of
their lives—chronic conditions. Potentially every aspect of one’s life can
be affected by chronic conditions. Because chronic conditions are highly
prevalent in the older population, gerontological nurses often are involved
in assisting patients with the demands imposed by these conditions. It is
important for gerontological nurses to understand the unique challenges and
goals for older patients living with chronic conditions. The success with
which a chronic condition is managed can make the difference between a
satisfying lifestyle in which control of the disease is but one routine
component and a life controlled by the demands of the disease.
KEY CONCEPT
The manner in which a chronic condition is managed can make the
difference between a high-quality, satisfying life and one in which the
person is a prisoner to a disease.
CHRONIC CONDITIONS AND OLDER

ADULTS
Medical technology has helped many people survive illnesses that once
would have killed them; greater numbers of people are reaching old age, in
which the incidence of chronic disease is higher. Thus, it should be no
surprise that more than 80% of older adults possess at least one chronic
disease. There is a profound increase in the rate of most chronic conditions
with age (Box 29-1), with most older adults having at least two (National
Council on Aging, 2017). This is particularly significant considering the
impact of these diseases on the individual older person who is affected. The
potential nursing problems associated with chronic conditions (Table 29-1)
highlight the disruption to physical, emotional, and social well-being.
TABLE 29-1 Potential Nursing Problems Associated With

Chronic Conditions of Older Adults
BOX 29-1 Major Chronic Conditions of Older
Adults
Hypertension
High cholesterol
Arthritis
Ischemic heart disease
Diabetes
Chronic renal disease
Heart failure
Depression
Alzheimer’s disease and other dementias
Chronic obstructive pulmonary disease
KEY CONCEPT
Most of the chronic conditions that are common in older adults can
significantly affect the quality of daily life.
GOALS FOR CHRONIC CARE

Most health professionals were educated in the acute care model, in which
care activities focus on diagnosis, treatment, and cure of illness. Within this
model, nursing actions are based on interventions that cure patients, and
success tends to be judged on how quickly and totally patients are able to
recover. Chronic conditions are an entirely different situation. Because
chronic diseases cannot be cured, it would be inappropriate to direct care
activities down a curative path. Rather, healing is of utmost importance.
Healing implies the mobilization of the body, mind, and spirit to
control symptoms, promote a sense of well-being, and enhance the quality
of life. The person with a chronic condition can learn to live effectively
with the disease and develop a sense of inner peace and harmony through
the recognition that he or she is defined by more than the physical body.
The nurse serves a healing role in facilitating this process and guiding
individuals with chronic conditions to achieve their maximum potential and
highest attainable quality of life. Rather than administer care and treatments
for or to patients, the nurse stimulates patients’ self-healing capabilities by
creating a therapeutic human and physical environment; educating;
empowering; reinforcing, affirming, and validating; and removing barriers
to self-care and self-awareness.
KEY CONCEPT
Healing implies the mobilization of the body, mind, and spirit to control
symptoms, promote a sense of well-being, and enhance the quality of
life.
Because patients cannot eliminate their disease, care measures focus on

helping patients effectively live in harmony with, rather than cure, the
condition. Professionals who seek success through the number of patients
who recover will be frustrated and disappointed when working with persons
who have chronic conditions; they must reorient themselves to a new set of
care goals (Box 29-2). The following goals are appropriate to chronic care:
BOX 29-2 Goals of Chronic Care

Maintain or improve self-care capacity
Manage the disease effectively
Boost the body’s healing abilities
Prevent complications
Delay deterioration and decline
Achieve the highest possible quality of life
Die with comfort and dignity
Maintain or improve self-care capacity. Chronic conditions often place

additional demands on people. They may need to eat special diets,
modify their activities, administer medications, perform treatments, or
learn to use assistive devices or equipment. Nurses may need to assist
patients in increasing their abilities to meet these needs. Actions
toward achieving this goal include education about the disease and its
management, stabilization and improvement of health status,
promotion of interest and motivation for self-care, use of assistive
devices, and provision of periodic assistance with care.
Manage the condition effectively. Individuals need to be
knowledgeable about their conditions and related care. Skills may need
to be mastered, such as injecting medications, changing dressings, or
applying prostheses. However, motivation is essential to mobilize
knowledge and skills in effective self-care, so assessing motivational
factors and planning and implementing strategies to enhance
motivation are crucial aspects.
Boost the body’s healing abilities. The body’s tremendous potential to
fight disease and heal naturally is often underestimated. Helping
patients mobilize natural resources is an important nursing function.
Stress management, guided imagery, exercise, immune-boosting
nutrients, and biofeedback are among the strategies that can promote
self-healing.
Prevent complications. Chronic diseases and conventional treatments
used to manage them can increase the risk of infections, injuries, and
other complications. Potential risks should be identified and actively
prevented, recognizing that risks change over time. Complications
must be prevented because they risk weakening self-care capacity,
increasing disability, and hastening decline. Whether a patient with
diabetes lives an active life or becomes a blind amputee is largely
determined by the extent to which treatment plans are followed and
complications are actively prevented.
Delay deterioration and decline. By their nature, chronic conditions
often progressively worsen. For example, a person with Alzheimer’s
disease will demonstrate a progressive decline in status even if highly
effective care is provided. However, preventive practices can influence
whether that individual is ambulatory or bed bound at the end of a
period. A conscious effort must be made to reinforce the importance of
preventive care measures and identify problems early.
Achieve the highest possible quality of life. Sitting in bed attached to
an oxygen tank may keep the body functioning but offers little
stimulation to the mind and spirit. Consideration should be given to
helping patients participate in activities that bring pleasure,
stimulation, and reward. The nurse should assess the extent to which
recreational, social, spiritual, emotional, sexual, and family needs are
met and provide assistance to fulfill those needs (e.g., introduction to
new hobbies, counseling for alternate positions for intercourse,
provision of transportation by specially equipped vehicles, and
arrangements for home visits by clergy). A positive self-concept needs
to be promoted. It is important for health professionals to periodically
evaluate the extent to which treatment of the condition promotes or
prohibits a satisfying lifestyle.
Die with comfort and dignity. As health status declines and patients
face their final days of life, they will need increasing physical and
psychosocial support. Pain relief, preservation of energy, provision of
comfort, and assistance in meeting basic needs become crucial. Nurses
also must be sensitive to the importance of listening and talking to
dying persons, anticipating their needs, assuring spiritual support, and,
most importantly, instilling a feeling that the nurse can be depended on
for support through this period.
The success and progress of goals of chronic care must be measured

differently from acute care. A deterioration of a patient from ambulatory to
wheelchair status can be judged a success if, without nursing intervention,
that patient may have become bedridden or died. Likewise, a physically and
emotionally comfortable death that left positive memories for the patient’s
family can be a significant accomplishment. These determinants of success
are different from those of acute care but are no less important.
KEY CONCEPT
Successes in chronic care are measured differently from those in acute
care.
ASSESSMENT OF CHRONIC CARE

NEEDS
Self-care capacities can vary considerably among persons who have chronic
conditions. The self-care capacity of the same individual will also vary at
different times throughout the course of the illness. Keen assessment and
reassessment are thus necessary. The nurse should review the individual’s
capacity to fulfill each of the health-related requirements, as well as the
person’s capacity to meet the demands imposed by illness (e.g., medication
administration, dressings, and special exercises). From this, the nurse can
determine deficits in fulfilling care needs.
A majority of people with chronic conditions manage their conditions
in a community setting, most likely with family support or involvement;
therefore, assessment must consider not only the capacity of the individual
to fulfill the care demands but also the capacity of the family to assist and
cope with caregiving. For example, a man with diabetes and severe arthritis
in his hands may not be able to manipulate a syringe for his insulin
injections, but his wife may be able to give him injections; thus, he does not
have a deficit in this area. Likewise, a victim of Alzheimer’s disease may
not be able to protect herself from safety hazards, but if she lives with a
daughter who supervises her activities, this patient may not have a deficit in
her ability to protect herself. Within this framework, the family is the
patient, and the capacities and limitations of the total family unit must be
evaluated. Remember that family is not limited to relatives but can include
a variety of significant others.
The nurse cannot assume, however, that the presence of family
members guarantees compensation for the patient’s care deficits.
Sometimes, the caregivers may not have the physical, mental, or emotional
abilities to meet the patient’s care needs. For instance, the patient’s
caregiver daughter may be a frail older adult herself. Likewise, the family
may not want to provide care because of the imposition on their lifestyle or
their feelings toward the patient. These factors must be considered before
care is delegated to family members.
Once identified, care needs should be reviewed with the patient and
family members. This not only helps to validate data but also promotes
understanding by all parties involved as to what the actual care needs are.
Methods of meeting care needs should be identified jointly (e.g., the
daughter will assist with bathing, the son will provide transportation to the
clinic for monthly visits, the daughter-in-law will call twice daily to remind
the patient to take medications). The nurse should inform the family of the
services available in their community to supplement their efforts. In fairness
to the family, the costs and limitations of community services must be
included in this discussion.
Part of the ongoing assessment should include the impact of the chronic
condition on the total life of the older adult. Having a chronic condition can
cause the patient to feel different from others and be self-conscious—for
example, when a person who is diabetic is unable to eat many of the foods
served at a family picnic and must withdraw to check blood glucose and
inject insulin. Likewise, chronic coughing that could be bothersome to
others, or the potential for a colostomy bag to leak, can discourage social
engagement. Social isolation can result due to the person not wanting to
cause an inconvenience or stand out from the others or due to others
excluding that person from social activities due to symptoms or care
activities. Feelings of being different and of powerlessness can arise as
well. Although the condition may be managed effectively, the quality of life
of the older adult may be suffering from the demands and stigma associated
with the condition. These issues should be reviewed and addressed during
assessment encounters.
Chronic disease can affect every aspect of life, making its impact
significant for older adults. How chronic disease is managed can be the
difference between a satisfying life and a life controlled by disease.
KEY CONCEPT
The patient and family caregivers should validate care plan priorities and
goals.
Identified care needs direct goals and plans for care. Setting goals is
important in helping patients and their families understand the realistic
direction of the condition. For instance, a long-term goal of restoring
ambulation sets a different tone from a goal of preventing complications as
function deteriorates. Acceptance of long-term goals may require
acceptance of the realities of the condition, which is not an easy task for
patients and their families. It may take time and considerable nursing
support for families to come to the understanding that the patient’s physical
or mental status will decline over time. This is not to suggest that hope
should be destroyed, but rather that it be tempered with a realistic sense of
what the future may hold. Short-term goals offer a means of evaluating
ongoing efforts and serve as benchmarks in care; these goals can be set on a
daily, weekly, or monthly basis, depending on the situation.
COMMUNICATION TIP
Written care plans are beneficial to patients and their families. Having
the plans in writing avoids discrepancies between perceptions and
reality. It also prevents directions from being forgotten and ensures
that anyone who participates in the patient’s care will have the same
understanding. Provide a written plan and related instructions in a
language and on a level appropriate for the patient and involved
family. It is helpful to have the patient’s caregiver or support person
present when the care plan is discussed so that all individuals assisting
the patient understand the recommended plan. This also can aid in
validating the ability of the plan to be followed.
POINT TO PONDER
How would your life change if you learned that you had a chronic
condition that would progressively worsen? What would you do
differently? From where and whom would you draw emotional and
spiritual support?
MAXIMIZING THE BENEFITS OF

CHRONIC CARE
With similar diagnoses and care requirements, one individual may remain
an active participant in society, enjoying a high quality of life, whereas
another may become a homebound prisoner to the disease. The difference
can depend on how the person approaches and manages care activities.

Because chronic conditions demand long-term medical supervision,
selection of a physician becomes a significant issue for the patient. The
patient should have contact with a specialist who is knowledgeable about
state-of-the-art practices related to the condition. The nurse may assist the
patient by providing the names of specialists for the patient to consider,
along with insurance that the provider accepts. In addition to qualifications
and expertise in the field, the patient should feel at ease with the physician;
a good chemistry between physician and patient will allow the patient to
ask questions freely, discuss concerns, and report problems. Some factors
that promote a positive physician–patient relationship include accessibility
of the physician, sufficient time allocation for office visits and telephone
consultations, comfortable and patient-appropriate communication style,
respect for patient’s involvement and decision-making, consideration of
needs of entire family unit, openness to alternative and complementary
therapies, and attitude of hope and optimism.
KEY CONCEPT
In addition to expertise in treating the specific condition, the physician
should have a style with which the patient is comfortable because the
relationship will be long term.
Patients have a responsibility to use their health care provider’s time

effectively. Patients can be advised to prepare for office visits by writing
down questions, symptoms, and concerns and to maintain their own records
of laboratory tests, vital signs, and other relevant medical data.

Anyone who has attempted a weight reduction diet or exercise program
appreciates the benefits of having a friend with whom the experience can be
shared. Likewise, the person who must face life adjustments every day for
the rest of his or her life can benefit from a buddy or coach who can partner
with the patient to provide support and assistance. The chronic care coach
can be a spouse, child, friend, or someone with a similar condition who
cares about and has regular contact with the patient (Fig. 29-1). The coach
may accompany the patient to diagnostic tests or routine office visits and
check on the patient’s status routinely. The coach can provide feedback and
positive reinforcement, as well as a listening ear when the patient has
“slipped off” the treatment regimen or regressed (Box 29-3). Also, the
coach can help the patient stay current about the disease by clipping articles
from magazines and sharing information gained through media features.
Gerontological nurses can advise and support persons who function as
chronic care coaches to older individuals by outlining some of the basic
steps of this process (Box 29-4).
FIGURE 29-1 A chronic care coach, whether a friend,

spouse, or someone with a similar condition, has regular
contact with the older person and can provide support and
assistance.
BOX 29-3 Functions of a Chronic Care Coach
Maintain regular contact with the patient.
Become informed about the chronic condition and its related care
requirements; keep abreast of new information, and share this with
the patient; gather information as needed.
Reinforce the care plan.
Help patient prioritize and organize care activities.
Assist patient in developing daily, weekly, and monthly goals.
Remind the patient of appointments, activities.
Acknowledge the realities of the condition.
Listen to concerns and accept reaction without judgment.
Offer feedback.
Use humor therapeutically. Engage in fun activities with patient.
Assist patient in locating and using resources.
Reframe problems into opportunities; challenge patient to consider
changes, new approaches.
Observe changes or signs that could indicate complications or
changes in condition; encourage patient to consult with health care
provider promptly.
Accompany patient to health care providers’ office visits as needed.
Recognize patient’s efforts at self-care and compliance and give
positive reinforcement.
Encourage patient to comply with care demands. Provide
inspiration and hope.
BOX 29-4 Steps in Chronic Care Coaching

Contact: Schedule regular telephone or face-to-face contact to check on
the patient’s status.
Observe: Be attentive to comments, mood, body language, energy,
general status, presence of symptoms, compliance.
Affirm: Reinforce care plan and actions; recognize patient’s efforts and
accomplishments.
Clarify: Ask questions; validate observations; correct misconceptions;
reinforce information.
Help: Offer assistance when self-care capacity is diminished; locate and
negotiate resources.
Inspire: Encourage patient to comply with care plan, build on positive
experiences and accomplishments; offer hope.
Nurture: Provide education, information, support.
Guide: Assist in setting realistic goals, developing plans, prioritizing,
seeking resources, and making decisions.
Reprinted with permission from Eliopoulos, C. (1997). Chronic care coaches: Helping people
to help people. Home Healthcare Nurse , 15 (3), 188.
KEY CONCEPT
A chronic care coach provides support, encouragement, reinforcement,
assistance, and feedback.
An informed patient is well equipped to manage the chronic condition
successfully and prevent complications. Also, knowledge helps empower
the patient. Various organizations for virtually every health condition can
provide useful educational materials, often free of charge (see the
Resources lists throughout this book). Most newspapers carry regular health
columns that provide current information on health conditions and
treatments. Local libraries not only possess a wealth of information on their
shelves but also can assist people with literature searches. Also, ever-
increasing numbers of individuals use the Internet to learn about new
information and share knowledge. (If patients do not own a computer, they
often can use one provided at public libraries.) Nurses should encourage
patients to obtain as much information as they can and to maintain a file on
their condition.

Support groups can be important for persons with chronic conditions; they
provide the opportunity not only for obtaining valuable information but also
in gaining perspectives from those living with similar situations. Patients
may be more willing to ask questions and express concerns with their peers
than with health care professionals. Most support groups can be located
through the Internet and local telephone directories or the information and
referral services of the local agency on aging; national headquarters of
organizations also can direct patients to local chapters.

Patients with lifelong health conditions need to commit to smart lifestyle
choices to maximize their health and quality of life, such as compliance
with the prescribed treatment plan, sound dietary practices, regular exercise,
stress management, assertiveness in protecting one’s own needs, and
development of a healing attitude and mind-set to live positively with the
condition.

Growing numbers of Americans use complementary and alternative
therapies for health promotion and illness management, and there is
increasing evidence of the effectiveness of these measures. Such therapies
use the body’s capacity to heal itself and place the patient in charge of the
healing process. Box 29-5 lists some of the alternative therapies that can be
used to complement conventional therapies. In some cases, complementary
and alternative therapies can replace conventional treatments, as when an
analgesic is replaced by the use of acupuncture or guided imagery. The fact
that complementary and alternative therapies have not been widely used in
this country in the past does not mean that they are ineffective; people in
other countries have used some of these measures successfully for
centuries. Furthermore, the scarcity of research supporting the use of some
of these therapies does not mean that they are useless. (Consider that
researchers stand a better chance of obtaining funds for well-understood
conventional therapies than for less familiar alternatives; pharmaceutical
companies are not going to invest large sums of money testing herbal
remedies that cannot be patented for their exclusive use; and most medical
researchers have been educated in a system that perpetuates the use of
conventional practices.)
BOX 29-5 Complementary and Alternative

Therapies for People With Chronic Conditions
Acupressure
Acupuncture
Aromatherapy
Ayurvedic medicine
Biofeedback
Chiropractic
Guided imagery
Herbal medicine
Homeopathy
Hydrotherapy
Hypnotherapy
Light therapy
Massage therapy
Meditation
Naturopathic medicine
Nutritional supplements
Osteopathy
Progressive relaxation
Qigong
Sound therapy
T'ai chi
Therapeutic touch
Yoga
This is not to say that there are not charlatans eager to take advantage of
people who have chronic conditions. The nurse plays a significant role in
helping the patient evaluate the validity of complementary and alternative
therapies and use only sound, safe practices. Patients should be encouraged
to discuss these therapies with their physicians and other health care
providers. (In some circumstances, patients may need to provide literature
about complementary and alternative therapies to their providers to educate
them about these practices!) Ideally, patients should be able to use the best
of both complementary/alternative and conventional health care practices.
KEY CONCEPT
Many individuals can benefit from using a combination of conventional
and complementary and alternative health practices for the care of their
conditions.
CONSIDER THIS CASE

You are making the initial visit to Mrs.
Johns, an 86-year-old patient who is part of an eldercare program that
provides monthly home visits to monitor community-based older adults
who have multiple health conditions. Mrs. Johns has hypertension,
osteoarthritis, COPD, glaucoma, and macular degeneration. She self-
administers oral medications and eye drops for these conditions. Widowed
10 years ago, Mrs. Johns lives alone and has a son who lives in another
state and a daughter who visits her weekly to assist with shopping and
chores. She has daily telephone contact with several friends and both of
her children.
Mrs. Johns is able to communicate clearly and states that she
“manages just fine”; however, during the home visit, the nurse learns that
Mrs. Johns is not taking her medications as prescribed and has run out of
her antihypertensive medication. When asked about the prescription that
was not refilled, she responds, “I was going to have my daughter take me
to the pharmacy, but I keep forgetting to ask her. She is so busy with her
kids I hate to bother her.” When discussing her next appointment with her
physician, Mrs. Johns states that she “had completely forgotten about it.”
When reviewing her typical daily activities, the nurse learns that Mrs.
Johns spends most of her day watching television because she doesn’t
have the energy to do much else. The nurse notices that the clothing Mrs.
Johns is wearing is soiled, and she has an odor indicating she hasn’t
adequately bathed for a while.
THINK CRITICALLY
1. How do you approach the discussion with Mrs. Johns of her need to
have additional assistance, and what type of assistance could be
considered?
2. What measures could be implemented to assist Mrs. Johns in
organizing and remembering her medication administration and
appointment schedules?
3. How would you approach the topic of exploring increased assistance
from Mrs. Johns’ daughter?
FACTORS AFFECTING THE COURSE

OF CHRONIC CARE
Anyone who has dieted can appreciate the difficulty of sustaining the initial
weight loss behaviors (e.g., food restrictions and exercise) on a long-term
basis without regular reinforcement and support. The same is true for the
new behaviors associated with managing a chronic condition. Persons with
chronic conditions cannot be given their instructions for care, discharged,
and forgotten. They will need periodic contact and reevaluation of their
capacity, resources, and motivation to manage their conditions.
A variety of factors can change patients’ abilities to manage their
illnesses. The status of the illness may change, placing more or different
demands on the patient. The status of the patient may change, reducing self-
care ability. The status of the caregiver may change, limiting the degree to
which the patient’s deficits can be compensated. All the factors affecting the
patient’s ongoing care must be evaluated regularly.

The lifestyle changes, frustrations, and losses commonly experienced by
persons who must live with chronic conditions may cause certain reactions
to emerge that could disrupt the flow of care. These reactions are defense
mechanisms, used when the situation at hand may be too much for the
patient to cope with, and include the following:
Denial: making statements or taking actions that are not consistent

with the realities of the illness (e.g., abandoning a special diet,
discontinuing medications independently, committing to
responsibilities that cannot be fulfilled)
Anger: acting in a hostile manner, having violent outbursts
Depression: making statements regarding the hopelessness of a
situation, refusing to engage in self-care activities, withdrawing,
questioning the purpose of life
Regression: becoming increasingly dependent unnecessarily,
abandoning self-care behaviors
These and other reactions are indications that the patient’s ego strength
is threatened and that extra support is needed. Rather than reacting to the
patient’s behavior, caregivers need to understand its origin and help the
patient work through it (e.g., by providing an opportunity to vent
frustrations and offering respite from the routines of care by doing for the
patient until he or she feels psychologically able to resume self-care).
Chronic conditions can have a profound impact on psychosocial function;
in turn, psychosocial function can impact the degree to which the individual
lives effectively with the chronic condition. Older adults who are dealing
with losses and changes may feel overwhelmed and powerless when faced
with chronic conditions. Self-concept can be altered as older persons
receive diagnoses that they had associated with old age. They may feel that
having chronic conditions causes them to be viewed as different, less
competent, or unattractive; they may be stigmatized due to the perception
others have of persons with specific diagnoses or due to behaviors that
foster stigmatization (e.g., feeling ashamed of their disease or identifying
themselves as inadequate due to having a specific diagnosis). They may
begin to identify themselves by their diagnosis or limitations (real or
perceived); others may impose such identities on them.
Patients need support as they adapt to their condition and
encouragement to adapt the chronic condition to their lives, rather than
having their lives turned upside down by their chronic condition. Many of
the recommendations discussed earlier will equip these individuals to live
effectively with their conditions and achieve optimum psychosocial health.
Specific psychosocial symptoms and history that could affect adaptation to
the chronic condition (e.g., expressions of hopelessness, attention-getting
benefits of sick role behaviors, poor coping capacity, and lack of support
system) should be considered during the assessment and interventions
planned to address them. Support groups can prove beneficial as they offer
contact with persons experiencing similar issues who can share successful
strategies, answer questions in a peer-to-peer manner, and provide examples
of living effectively with the condition.

In the home management of a chronic illness, the entire family is the
patient; therefore, in evaluating care, the impact on the total family must be
considered. The patient with Alzheimer’s disease may be well groomed,
well nourished, and free from complications; looking at the patient in
isolation, an evaluation could be made that her home care has been
successful. However, the patient’s status may have been achieved at great
cost to the entire family. For example, her husband may have had to forfeit
his job to care for her during the day; her daughter’s family life may have
been disrupted because she needs to sleep at her parents’ home to assist her
father in controlling her mother’s night wandering; the son’s plans to
expand his business may have been postponed because he began
subsidizing his parents’ income. Some sacrifices and compromises are
common when family members assume caregiver roles, but serious
disruption to their health or their lives should not result. Families may be so
embroiled in the situation that they are unable to see the full impact that the
caregiving situation is having on their own lives. Sometimes they feel that
they must be a “bad” spouse or child to feel that the patient’s care is a
burden. Nurses can assist by helping family members realistically evaluate
their caregiving responsibilities and identify when other caregiving options
should be considered. For instance, the family may sense that it is in the
patient’s best interest to enter a nursing home, but they need the health care
professional to introduce the suggestion and help them through the process
of making this difficult decision.
KEY CONCEPT
In chronic care, the entire family is the patient.

Although only 5% of the older population is in a nursing home or other
institutional setting at any given time, nearly one half of all older women
and one third of all older men will spend some time in a long-term care
facility during their lives (National Center for Health Statistics, 2019). Most
families seek assisted living or nursing home care after having attempted
caregiving of their elder relative at home, not as a first choice. By the time
they seek such assistance, their physical, emotional, and socioeconomic
resources can be significantly depleted, and they may require special
support and assistance from nurses. (Chapter 34 discusses the care of
individuals who are in long-term care facilities.)
POINT TO PONDER
What would you do if a parent, spouse, or child needed considerable
care? How much care could you realistically provide, and what resources
would you have available?
CHRONIC CARE: A NURSING

CHALLENGE
Effective chronic care is not an easy nursing challenge. It requires
knowledge and skills related to the management of multiple medical
problems, skilled assessment and planning, individualized promotion of
self-care capacity, monitoring of family health, and a variety of other
demands. The patient’s comfort, independence, and quality of life are
largely influenced by the type of services rendered; in chronic care, most of
those services will fall within the scope of nursing. Perhaps this type of
care, more than any other, provides an opportunity for nursing to
demonstrate its facets of independent practice and full leadership potential.
Arthritis-Related Functional Limitations and

Inadequate Physical Activity Among Female
Adult Cancer Survivors
Source: Park, S. H. & Strauss, S. M. (2020). American Journal of Nursing,
120(3), 26–31.
Despite the recommendations for physical activity that are promoted,
inadequate physical activity often is the finding, both in healthy adults and
cancer survivors. Research has identified characteristics of cancer survivors
with inadequate physical activity as being of older age, minority race, lower
education level, obese, and with a history of smoking, depression, and
health or mobility restrictions. The greatest cause of mobility restriction is
arthritis, both in cancer survivors and those who have never had cancer.
Women tend to be affected with arthritis more than men.
This study examined the degree to which functional limitations arising
from arthritis were predictive of low physical activity levels in 729 women
who were cancer survivors. Their responses to the National Health and
Nutrition Survey, which incorporates a physical activity questionnaire, were
analyzed. The questionnaire examined how many days and minutes per day
the women participated in physical activity. The majority of respondents
were white, 65 years of age or older, overweight or obese, with at least a
high school education, and no signs of clinical depression. Women over age
65 years were found to have inadequate levels of physical activity 1.2 to 2.4
times greater than those under age 65. Being overweight or obese, having
clinical depression, and having functional limitations from arthritis
increased the likelihood of inadequate physical activity.
Because arthritis is among the leading chronic conditions in older
adults, it will likely influence physical activity in this population; the
presence of other chronic conditions or being a cancer survivor further
increases the likelihood of inadequate physical activity. It is important for
nurses to consider these factors when assessing and monitoring older adults
with chronic conditions. Whenever an older adult is seen by a health
professional—such as when receiving an annual physical or being
hospitalized for the treatment of COPD or hypertension, engagement in
physical activity is an important topic to review and address. Counseling
and education should include the importance of physical activity, types of
activities that can be beneficial (e.g., walking, swimming, cycling), and
approaches to building strength and endurance. Based on findings, nurses
can suggest physical or occupational therapy referrals and assist patients in
locating potential sites in their communities in which exercise groups and
gyms can be found. Many senior citizen centers offer exercise programs
that provide free or low-cost exercise as well as opportunities for
socialization. Nurses can make an important contribution by assuring that in
the management of patients’ chronic conditions, a holistic approach is used
that considers all facets of health promotion, including diet, exercise, sleep,
rest, elimination, safety, emotional well-being, and socialization.
PRACTICE REALITIES
You are joining a new geriatric specialty medical practice with a team of
nurses, nurse practitioners, and physicians. The team recognizes that
chronic conditions are a major challenge for the population they are
targeting and want to offer services addressing this challenge. They want to
“think outside the box” in developing innovative approaches and assign you
the task of designing an assessment tool that evaluates the holistic needs of
the person who has a chronic condition.
Describe the components of the assessment tool you would develop.

1. Discuss the way in which your life would be affected if you developed
a chronic disease. What additional issues exist for an older adult faced
with this same situation?
2. Review the major chronic illnesses affecting the older population and
identify the threats to the quality of life that could be associated with
each.
3. Describe factors that cause most nurses and physicians to be ill-
informed of or resistant to alternative therapies.
4. Identify measures that could help empower an older adult who has a
chronic condition.

questions.
The home health nurse is making the initial visit to Mr. Petrovich, an 84-
year-old client who is part of an eldercare program that provides bi-
monthly home visits to clients with multiple medical diagnoses.
Nurse’s Notes
1300: Mr. Petrovich has hypertension, osteoarthritis, chronic obstructive
pulmonary disease (COPD), glaucoma, and macular degeneration. He
self-administers oral medications and eye drops for these conditions. The
client has a son who lives in another state and a daughter who visits
weekly to assist with shopping and chores. He has daily telephone and
internet contact with several friends and both of his children.
Mr. Petrovich communicates clearly, stating, “I mostly do okay
managing things for myself”; however, during the home visit, the nurse
learns that he hasn’t had his antihypertensive medication prescription
refilled and so is not taking his medications as prescribed. When asked
about the lapse in his prescription refill, he responds, “I’ll have my
daughter take me to the pharmacy when she isn’t so busy.” When
discussing his next appointment with his primary care provider (PCP),
Mr. Petrovich states that he “will get around to making an appointment.”
When reviewing his typical daily activities, the nurse learns that Mr.
Petrovich spends most of the day watching television because he lacks
the energy to do much else. The nurse notices that the clothing he is
wearing is soiled and that he needs a shave and haircut. He has an odor,
indicating he hasn't adequately bathed for a while.
Chapter Summary
Most older adults will have at least one chronic condition that has the
potential to impact the quality of their lives. Rather than emphasizing
curing, the focus of chronic care is on healing—meaning the person uses
the resources within body, mind, and spirit to achieve the highest possible
quality of life with the condition. Nurses play a significant role in assisting
persons with chronic conditions in this process.
Whereas the primary goals of acute care are to diagnose, treat, and cure,
in chronic care, the goals are to maintain or improve self-care capacity,
manage the condition effectively, boost the body’s healing abilities, prevent
complications, delay deterioration and decline when it is unavoidable,
achieve the highest possible quality of life, and die with comfort and
dignity. These goals require nurses to assess their progress differently than
they would in the acute care setting.
Care plans developed for persons with chronic conditions need to be
realistic and acceptable to the patient and, as appropriate, family members
who may be assisting with caregiving. Measures that can facilitate the
patient’s ability to meet and sustain care requirements include the
following: selecting an appropriate physician who not only is
knowledgeable about the condition but with whom the patient feels
comfortable, using a chronic care coach, increasing the patient’s knowledge
about the condition by providing and linking the patient and caregivers with
resources, joining a support group, making wise lifestyle choices, and using
complementary and alternative therapies. The nurse can provide guidance
and support to help the patient locate and utilize these measures.
Living with chronic conditions can be challenging and cause patients to
utilize defense mechanisms that can interfere with the flow of care. Support
is needed to enable patients to work through these stages. Families may
need explanations of the reactions they are seeing patients display. In
chronic care, it is especially important to remember that the entire family is
the patient and consider the family unit’s needs in planning care.
References
National Center for Health Statistics. (2019). Long-term care providers and services users in the
United States, 2015–2016. Vital and health statistics , 3 (43), 19–24.
National Council on aging. (2017). Top 10 chronic conditions in adults 65+. Retrieved April 21,
2020 from https://www.ncoa.org/blog/10-common-chronic-diseases-prevention-tips/
UNIT 5
Settings and Special Issues in
Geriatric Care
30 Spirituality
33 Acute Care
34 Long-Term Care
36 End-of-Life Care
CHAPTER 30
Spirituality
Chapter Outline
Spiritual Needs
Love
Meaning and Purpose
Hope
Dignity
Forgiveness
Gratitude
Transcendence
Expression of Faith
Assessing Spiritual Needs
Addressing Spiritual Needs
Being Available
Promoting Hope
Assisting in Discovering Meaning in Challenging Situations
LEARNING OBJECTIVES
1. Describe basic spiritual needs.

2. List questions that could be used for spiritual assessment.
3. Discuss measures to support spiritual needs.
TERMS TO KNOW
Agnostica person who claims not to know with certainty whether or not
God exists
Atheista person who believes God does not exist
Faithbelief in God, a higher power, or system of religious beliefs
Lack of spiritual well-beinga disruption to the beliefs or practices related
to one’s faith or relationship with God or other higher power, causing
spiritual needs to be unfulfilled
Religionhuman-created structures, rituals, symbolism, and rules for
relating to God/higher power
Spiritualityrelationship and feelings with that which transcends the
physical world
Most people are comforted by the knowledge that they have a connection
with a power that is greater than themselves. A positive, harmonious
relationship with God or other higher power (the Divine) helps individuals
to feel unified with other people, nature, and the environment. It offers them
love and a sense of having value, despite their imperfections or errors.
People derive joy, hope, peace, and purpose when they transcend beyond
themselves. Suffering and hardship can have meaning and be faced with
added strength.
Spirituality is the essence of our being that transcends and connects us
to the Divine and other living organisms. It involves relationships and
feelings. Spirituality differs from religion , which consists of human-
created structures, rituals, symbolism, and rules for relating to the Divine.
Religion is a significant expression of spirituality, but it is possible for
highly spiritual individuals not to identify with a specific religion.
KEY CONCEPT
Spirituality and religion are not synonymous.
The fact that some individuals identify with being an atheist or

agnostic does not mean they are not spiritual beings. Atheists believe with
certainty that no superior being or gods exist. Agnostics doubt that any
superior being or gods exist but don’t know for certain. The fact that people
are atheists or agnostics does not mean that they are not spiritual, because
they can search for meaning in their lives, have a strong sense of moral
values, and be in awe at the mysteries and wonders of life.
SPIRITUAL NEEDS
All humans have spiritual needs, regardless of whether they realize or
acknowledge them. Some of these needs become particularly relevant in
late life when the high prevalence of chronic illness and reality of death are
evident; these needs can include love, purpose, hope, dignity, forgiveness,
gratitude, transcendence, and faith.
Love
Love is probably the most important spiritual need of all. People need to
feel that they are cared for and can offer caring feelings. Spiritual love is
not quid pro quo in which it is offered to obtain something in return. Rather,
spiritual love is unconditional—offered unselfishly, completely. In the
Judeo-Christian tradition, this type of love is exemplified by the type God
has for people. People need to feel loved regardless of their physical or
mental condition, social position, material possessions, or productivity.
Meaning and Purpose

According to Erikson’s description of the final developmental task (see
Chapter 2), healthy psychological aging for the older adult involves
achieving a sense of integrity. This integrity, or wholeness, is supported by
the belief that life experiences—both good and bad—make sense and have
served a purpose. Some individuals may believe, based on their faith, that
suffering and sorrow have eternal purposes or allow God to be glorified.
With this perspective, nothing is in vain, and one’s significance in the world
is better understood.
Hope
Hope is the expectation for something in the future. For some people, hope
consists of the anticipation that opportunities for new adventures, pleasures,
and relationships will unfold with each tomorrow. For others, hope propels
them to face the future in the presence of pain and suffering, because they
believe relief and eternal reward are possible.
Dignity
In the Western society, self-worth is often judged by one’s appearance,
function, and productivity. Yet, every human being has intrinsic worth.
When older people lack the attributes that command dignity for most of the
secular society, they can derive a sense of value and worth through their
connection with God or other higher power.
Forgiveness
It is human nature to err and sin. Carrying the burden of the wrongs
committed by or to oneself is significantly stressful and can detrimentally
affect health. Furthermore, being unforgiving can rob people of the love and
fulfillment derived through relationships. Forgiving and accepting
forgiveness is healing. For older adults, forgiveness can facilitate the
important process of putting things in order and achieving closure to
unfinished business.
Gratitude
The abundance that is so prevalent in the Western society sometimes causes
much to be taken for granted. Rather than appreciating that they are not
hungry or homeless, people may complain that they have not dined at
certain restaurants or that their home lacks a pool. They focus on having
undesirably large thighs rather than giving thanks for being able to walk.
Instead of being appreciative that their children are healthy, they are
distressed that they are not the parents of an honor roll student. It is easy to
fall into the trap of focusing on the negatives. However, an attitude of
thankfulness nourishes the spirit and strengthens the ability to cope with
any situation. At a time when losses may be many, older individuals may
benefit from a guided review of the positive aspects of their lives. The life
review process is a good approach to use in this effort (see Chapter 4).
Transcendence
People need to feel that there is a reality beyond themselves, that they are
connected to a greater power that surpasses logical thinking, and that they
have a source that empowers them to achieve that which they cannot
achieve independently. Transcendence affords people life beyond material
existence and equips them to make sense of the difficult circumstances they
face (Fig. 30-1).
FIGURE 30-1 By feeling a connection with a reality

beyond their material existence, people can navigate the
difficult circumstances they face.
Expression of Faith
Faith encompasses religious/spiritual beliefs and is expressed through
religious/spiritual practices. These practices can include prayer, worship,
scripture reading, rituals (e.g., fasting on certain days or wearing special
articles of clothing), and celebration of specific holy days. Disruption in the
ability to express one’s faith because of illness or disability can lead to one
feeling spiritually unfulfilled. Likewise, the lack of spiritual fulfillment can
arise during illness from a person feeling resentful that God has seemingly
abandoned him, guilty that the illness may be a means of punishment for
sin, or regretful that he lacks a strong faith to support him through the
situation.
POINT TO PONDER
Which spiritual need is most difficult for you to fulfill personally? Why?
ASSESSING SPIRITUAL NEEDS

Asking about spiritual matters as part of the initial and ongoing assessment
fosters holistic care. Although various clinical settings have assessment
tools preferred for use, elements that spiritual assessment should address
include faith beliefs and practices, affiliation with a faith community, and
the extent to which spiritual needs (e.g., love, meaning, purpose, hope,
dignity, forgiveness, gratitude, transcendence, and expression of faith) are
satisfied.
The nurse has several sources for gathering information about a
person’s spiritual needs. The person’s response to spiritual/religious
preference on routine admission forms can give some indication of the
patient’s spirituality and provide a lead for a discussion of other issues
pertaining to spirituality. Visible cues, such as the wearing of a religious
article or presence of religious symbols, Bible, Koran, and inspirational
books, can provide insights useful in spiritual assessment. A person’s
comments (e.g., “All I can do now is pray” or “I can’t understand why God
would allow this to happen”) may offer clues about spiritual needs.
Depression, a flat affect, crying, and other observable signs can be a red
flag for the lack of spiritual well-being or spiritual distress. In addition, the
nurse can ask specific questions to explore spiritual needs. Assessment
Guide 30-1 outlines questions the nurse can ask to assess a patient’s
spirituality.

SPIRITUAL NEEDS
INTERVIEW
As part of a holistic assessment, ask questions that directly address the
person’s spirituality and spiritual needs. Questions may include the
following:
What is your faith or religion?

Are you involved with a church, temple, or faith community? What is
it? Would you like to have them involved with your care?
Are there religious practices that are important to you? Are you able
to practice them now? If not, is there a way I can assist you in
practicing them?
Do you believe in God or a higher power? Could you please describe
what that belief means to you?
Do you read the Bible or other religious text? Are you able to do this
reading now?
What do you think God’s role is in your illness and healing?
Is there anything about your faith or spiritual beliefs that is causing
you distress, discomfort, or conflict?
What is most meaningful to you?
What gives your life purpose?
What is your source of strength or support?
From whom do you receive love?
Who are the most significant recipients of your love?
Do you feel like you have unfinished business? Things you need to
say to someone? Forgiveness you wish to seek or offer?
What are your fears?
How can I (we) best support your spiritual beliefs and practices at
this time?
COMMUNICATION TIP
When assessing and discussing spiritual needs with a patient, in
addition to determining the patient’s religious identity, the nurse
should explore those things that offer meaning and purpose to the
person. In many circumstances, this can be the assurance of a
relationship with God, but the atheist and agnostic will also have
important aspects to their lives from which they derive meaning,
purpose, and peace. Keep in mind that persons of similar faiths may
have different ways of expressing their spirituality. It is important for
the nurse to listen without judgment and encourage the patient to
express spiritual beliefs and needs, even if they are in conflict with the
nurse’s beliefs.
ADDRESSING SPIRITUAL NEEDS

Evidence suggests that strong spiritual beliefs facilitate health and healing;
therefore, it is therapeutically beneficial to support patients’ spirituality and
assist them in fulfilling spiritual needs. When assessment reveals specific
spiritual needs or signs of the lack of spiritual well-being (see Nursing
Problem Highlight 30-1), nurses can plan strategies to address these specific
needs. In addition, nurses can use a variety of interventions to assist patients
and support their spirituality; these interventions are discussed in the
following sections.
LACK OF SPIRITUAL WELL-BEING
Overview
A lack of spiritual well-being implies a state in which there is an actual or
perceived disruption to one’s relationship with God or other higher power,
and/or spiritual needs cannot be fulfilled. Illness or declining health of self
or significant others, losses, awareness of mortality, and conflicts between
beliefs and medical treatments are factors that could promote a lack of
spiritual well-being. Signs of a lack of spiritual well-being could include
anger, anxiety, complaints, crying, cynicism, depression, guilt,
hopelessness, isolation, low self-esteem, powerlessness, refusal to make
plans, sarcasm, suicidal thoughts or plans, and physical symptoms
(fatigue, poor appetite, sleep disturbances, and sighing). The person may
question his or her faith and beliefs.
Serious illness, losses, added burdens, inability to engage in religious
practices, and association of current health problems with past sinful
behavior or lack of faith.
Goal
The patient discusses issues pertaining to lack of spiritual well-being,
maintains/establishes spiritual/faith-based practices to the maximum
degree possible, and develops support systems to promote spiritual well-
being.
Interventions
Assist the patient in identifying factors contributing to the lack of
spiritual well-being.
Support the patient’s religious practices: learn about the patient’s
religious practices and implications for care; provide Bible or other
religious text, religious articles, and inspirational music; respect
periods of solitude; respect and assist with practice of rituals; read
scripture or arrange for a volunteer to do so.
Pray with or for the patient if this does not violate the patient’s or
your own faith.
Provide the patient with privacy and time for prayer, meditation, and
solitude.
Refer to clergy, native healer, support group, or other resources.
Contact patient’s church or temple for visitation and follow-up (e.g.,
via parish nurse); link the patient with community health ministry if
the patient desires.
Respect the patient’s desire not to be visited by clergy or participate
in religious activities.
Do not challenge the patient’s religious beliefs or attempt to change
them.
Being Available
The closeness and trust that patients feel toward nurses facilitate their
sharing of deep feelings with nurses more than with other members of the
health care team. Nurses need to honor this trust and be available for
patients to express their feelings. This means not only being physically
available but also being fully present with patients without being distracted
or thinking about other activities. There may be times when nurses may not
know how to respond to spiritual needs or hear expressions of beliefs that
differ from their own; in these situations, attentive listening and
encouraging communication remain important.
KEY CONCEPT
Being present with a patient implies that the nurse is not only physically
with the individual but also offering undivided attention to facilitate a
true connection.
A good spiritual assessment should reveal specific beliefs and practices that
the nurse may need to facilitate. These practices can include the following:
special diets, refusing to participate in certain care activities on one’s
Sabbath, wearing of specific articles of clothing, and praying at specific
times of the day. Box 30-1 outlines some common religious beliefs and
practices nurses may encounter.
BOX 30-1 Religious Beliefs and Practices

Relevant to Gerontological Nursing Practice
PROTESTANTISM
Assemblies of God (Pentecostal): Encourage abstinence from
tobacco, alcohol, and illegal drugs; believe in divine healing
through prayer and laying on of hands; communion provided by
clergy; believe in Jesus Christ as Savior; pray for God’s
intervention in healing
Baptist: Encourage abstinence from alcohol; communion provided
by clergy; Scripture reading important as Bible viewed as word of
God; believe in Jesus Christ as Savior; may believe illness is God’s
will and respond passively to care; some believe in healing power
of laying on of hands (more than two dozen different groups in
United States)
Christian Church (Disciples of Christ): Communion part of regular
Sunday worship, provided by clergy; clergy and church elders can
provide spiritual support; believe in Jesus Christ as Savior
Church of the Brethren: Clergy provides anointing of sick for
physical healing and spiritual well-being; communion provided by
clergy
Church of the Nazarene: Abstinence from tobacco and alcohol;
believe in divine healing but accept medical treatment; communion
provided by clergy
Episcopal (Anglican): Fasting not required, although some
Episcopalians may abstain from meat on Fridays; communion
provided by clergy; anointing of sick may be offered although not
required; believe in Jesus Christ as Savior
Lutheran: Communion provided by clergy; anointing of sick by
clergy; provide service of Commendation of the Dying; believe in
Jesus Christ as Savior (10 different branches)
Mennonite: Abstain from alcohol; prayer has important role during
crisis or illness, as well as anointing with oil; may oppose
medications; women may desire to wear head covering during
hospitalization; simple and plain lifestyle and dress style;
communion provided twice a year with foot washing part of
ceremony (12 different groups)
Methodist: Communion provided by clergy; anointing of sick;
praying and reading Bible important during illness; organ donation
encouraged; believe in Jesus Christ as Savior (more than 20
different groups)
Presbyterian: Communion provided by clergy; clergy or elders can
provide prayer for the dying; believe in Jesus Christ as Savior; there
are several denominations of Presbyterianism
Quaker (Friends): Believe God is personal and real and that any
believer can achieve communion with Jesus Christ without the use
of clergy or church rituals; no special death ceremony because of
belief that present life is part of God’s kingdom; abstain from
alcohol; may oppose the use of medications
Salvation Army: Follow Bible as foundation for faith; Scripture
reading is important; no special ceremonies; offers social welfare
programs and centers; open to medical treatment; officer of the
local army can be called for visitation and assistance
Seventh-Day Adventist: Healthy lifestyle practices are promoted as
the body is seen as a temple of the Holy Spirit; alcohol, tobacco,
coffee, tea, and recreational drugs are prohibited; pork and shellfish
are avoided by most, and many are vegetarians; Sabbath is observed
on Saturday; treatment may be opposed on Sabbath; communion
provided by clergy; Bible reading important
ROMAN CATHOLICISM
Believe in Pope as head of the church on earth; express faith mainly in
formulated creeds, such as Apostle’s Creed; fasting during Lent and on
Fridays optional, although older Catholics may adhere to practice; priest
provides communion, Sacrament of the Sick, and hears confession;
rosary beads, medals, statues, and other religious objects important.
EASTERN ORTHODOXY
Includes Greek, Serbian, Russian, and other orthodox churches; believe
that Holy Spirit proceeds from Father (rather than Father and Son);
therefore, reject the authority of Pope; fast from meat and dairy products
on Wednesdays and Fridays during Lent and on other holy days; follow
different calendar for religious celebrations; fast during Lent and before
communion; holy unction administered to sick but not necessarily as last
rites; last rites must be provided by ordained priest.
OTHER CHRISTIAN RELIGIONS
Christian Science: Religion based on use of faith for healing; may
decline drugs, psychotherapy, hypnotism, vaccination, and some
treatments; use Christian Science nurses and other practitioners and
may desire that they be active participants in care
Jehovah’s Witnesses: Discourage the use of alcohol and tobacco;
blood transfusions not accepted, although alternative methods can
be used
Mormons (Church of Jesus Christ of Latter Day Saints): No
professional clergy; communion and anointing of sick/laying on of
hands can be provided by the member of church priesthood; abstain
from alcohol; discourage the use of caffeine, alcohol, and other
substances that are considered unhealthy and harmful; a sacred
undergarment may be worn at all times that is only removed in
absolute emergencies; prayer and reading sacred writings important;
may oppose some medical treatments and use divine healing
through laying on of hands
Unitarian: Highly liberal branch of Christianity; belief in God as
single being rather than doctrine of the Trinity; believe individuals
are responsible for their own health state; advocate donation of
body organs
JUDAISM
Believe in one universal God and that Jews were specially chosen to
receive God’s laws; observe Sabbath from sundown Friday to nightfall
Saturday; three branches:
Orthodox (observant): Strictly adhere to traditions of Judaism;

believe in divinely inspired five Books of Moses (Torah); follow
Kosher diet (not mixing of milk and meat at a meal, no pork or
shellfish, no consumption of meat not slaughtered in accordance
with Jewish law, use of separate cooking utensils for meat and milk
products); strict restrictions during Sabbath (no riding in car,
smoking, turning lights on/off, handling money, using telephone or
television; medical treatments may be postponed until after
Sabbath); men do not shave with razor but may use scissors or
electric razor so that blade does not come in contact with skin, men
wear skullcaps at all times; beard is considered sign of piety;
Orthodox man will not touch any woman other than those in his
family; married women cover their hair; family and friends visit and
may remain with dying person; witness needs to be present when a
person prays for health so that if death occurs family will be
protected by God; after death, body should not be left alone and
only an Orthodox person should touch or wash the body; if death
occurs on Sabbath, Orthodox persons cannot handle corpse but
nursing staff can care for the body wearing gloves; body must be
buried within 24 hours; autopsy not allowed; any removed body
parts must be returned for burial with the remaining body as they
believe all parts of the body need to be returned to earth; prayer and
quiet time important
Conservative: Follow same basic laws as Orthodox; may only cover
heads during worship and prayer; some may approve of autopsy
Reform: Less stringent adherence to laws; do not strictly follow
Kosher diet; do not wear skullcaps; attend temples on Fridays for
worship but do not follow restrictions during Sabbath; men can
touch women
ISLAM (MUSLIM)
Second largest monotheistic (belief in one God) religion; founded by
prophet Mohammed who was a human messenger or prophet used by
God to communicate His word; Koran is a scripture; Koran cannot be
touched by anyone ritually unclean, and nothing should be placed on
Koran; may pray five times a day facing Mecca; privacy during prayer is
important; abstain from pork and alcohol; all permissible meat must be
blessed and killed in a special way; cleanliness important; at prayer time,
washing is required, even by the sick; accept medical practices if these
do not violate religious practices; women are very modest and not
allowed to sign consent or make decisions without husband; may wear a
taviz (black string with words of Koran attached); family or any
practicing Muslim can pray with dying person; prefer for family to wash
and prepare body of deceased (if necessary, nurses can care for the
deceased body wearing gloves); autopsy prohibited except when legally
mandated; organ donation not allowed.
HINDUISM
This is considered one of the world’s oldest religions; religion of most of
India’s residents; no scriptures, fixed doctrine, or common worship;
belief in karma (every person born into position based on deeds of
previous life) and reincarnation; illness may be viewed as a result of sin
from past life; mostly vegetarian; abstain from alcohol and tobacco.
BUDDHISM
Offshoot of Hinduism with most followers in Japan, Thailand, and
Myanmar; believe enlightenment found in individual meditation rather
than communal worship; follow moral code known as Eightfold Path
that leads to nirvana (form of liberation and enlightenment); vegetarian;
abstain from alcohol and tobacco; may oppose medications and refuse
treatments on holy days; private, uninterrupted time for meditation
important.

Married women who are Orthodox Jews keep their hair covered at all
times. Those who follow Conservative Judaism cover their hair only
during worship and prayer.

Solitude can be an important aspect of the expression of spirituality.
Uninterrupted time allows personal communication with one’s god or other
higher power. One can offer prayers, reflect, meditate, and listen for
answers from the divine source (Box 30-2). Nurses must respect and protect
periods of solitude for their patients.
BOX 30-2 Meditation

Solitude provides an opportunity for meditation, an activity that calms
the mind and assists in focusing thoughts to the present. It can take the
form of:
concentrative meditation—attention is focused on breathing, a

sound, or an image; this calms and promotes mental clarity and
acuity
mindfulness meditation—attention is paid to sensations being
experienced, such as sounds or thoughts; this promotes a calm,
nonreactive mental state
transcendental meditation—introduced by Maharishi Mahesh Yogi,
this form involves guiding the body to a level of profound
relaxation while the mind becomes more alert
Meditation has many health benefits, including stress reduction,

stimulation of immune function, and pain control. Older adults may
benefit from the improved self-esteem and higher levels of mental
function that are allegedly achieved.
POINT TO PONDER
Choosing solitude differs from being socially isolated. How much time
do you build into your typical week for private time or solitude?
Promoting Hope
Hope is important to human beings. When people believe in the future and
believe that something positive is possible, they are likely to commit to
goals and actions. For older adults, especially those with serious health
conditions or disabilities, maintaining hope can be challenging. The risk of
feeling hopeless and depressed is real. Hopelessness can interfere with self-
care and healing and drain energies that are needed to face life’s challenges.
Promoting hope begins with establishing a trusting relationship with the
patient so that he or she will be comfortable in expressing feelings openly.
A careful assessment can assist in identifying factors that contribute to
hopelessness, such as strained family relationships, unrelieved pain, and
growing financial problems; interventions should be planned to address
specific factors. Other beneficial actions include the following:
assisting the patient in developing realistic short-term goals and

acknowledging the achievement of goals
guiding the patient in life review to highlight past successes in meeting
life challenges that can be linked to current situations
helping the patient to find pleasure and enjoyment in current life
activities
encouraging a relaxing, uplifting environment (e.g., flowers, fresh air,
sunlight, pleasant scents, pets, and stimulating colors)
facilitating the patient’s spiritual practices; referring to clergy as
needed
assisting the patient in participating in religious services
developing affirmations (positive statements, such as “I am a unique
and special individual” or “I am loved by God”) for the patient to use
and recommending they be repeated daily
suggesting that the patient maintain a personal journal to promote self-
understanding and personal growth
using music therapeutically; consulting with the music therapist for
selections that promote optimism and hope
referring to a support group
using humor therapeutically; conveying hope and optimism
Assisting in Discovering Meaning in Challenging
Situations
Patients may question the purpose of the difficulties they face or believe
that God has abandoned them. Persons of faith may want to discuss their
perspective on how their current situation fits into a larger plan. An open,
nonjudgmental attitude when encouraging the expression of feelings can
prove useful.
KEY CONCEPT
Some people’s faith can enable them to be comforted in believing that
their current challenges serve a positive purpose for God.

Patients may have a desire for communion, confession, and other religious
sacraments. Nurses may contact clergy as needed. Nurses can also assist
patients in wearing or displaying religious articles and ensure the safe care
of these articles during nursing activities.

People of faith have long understood the value of prayer, and now growing
research evidence supports the positive relationship between prayer and
health and healing (Choie & Hastings, 2018; Malone & Dadswell, 2018;
Ofstedal et al., 2019). One need not be an ordained clergy to hold a patient’s
hand and offer a prayer. Prayers can be specific, for example, that the
medication just administered will relieve the pain soon. The use of flowery
or “religious” vocabulary is less important than having the heart to ask a
higher power to intervene on the patient’s behalf. Intercessory prayers can
be offered for patients. Nurses who are not comfortable in offering prayers
themselves can ask coworkers who are willing to pray with and for their
patients if the patients desire it.
CONSIDER THIS CASE
While standing outside a shared patient

room, a nurse overhears 75-year-old Mrs. McQueen ask her roommate in
the other bed, 66-year-old Mrs. Noonan, if she belongs to a church. Mrs.
Noonan responds, “No…I don’t believe in that stuff. To me, religion is just
a crutch.” Mrs. McQueen, sounding quite upset, tells Mrs. Noonan, “You
shouldn’t say that. We need to honor the Lord. Don’t you want to be
healed?” Mrs. Noonan shouts back, “I’ll trust the doctors to heal me, not
some imaginary figure in the sky!” and pulls the curtain between the beds.
THINK CRITICALLY
1. How should the nurse respond to this situation?
2. What effects could this interaction have on each patient?
POINT TO PONDER
What would it mean to you to have someone pray for your needs or
struggles?
Religion, Life Expectancy, and Disability-Free

Life Expectancy Among Older Women and Men
in the United States
Source: Ofstedal, M. B., Chiu, C. T., Jagger, C., Saito, Y., & Zimmer, Z.
(2019). The Journals of Gerontology. Series B, Psychological Sciences and
Social Sciences , 74 (8), 107–118.
Some studies have shown a positive relationship between religion and
health; other research has indicated a positive relationship between religion
and survival. This study reviewed data to identify the relationship between
religion and a longer, disability-free life expectancy. The importance of
religion and attendance at religious services were considered predictors.
Disability was evaluated by participants in terms of function with activities
of daily living and instrumental activities of daily living. The results
showed that older adults who attended religious services at least weekly
lived between 1.1 and 5.1 years longer, and lived more years without
disability. To a lesser degree, there was also a positive relationship between
the older adults’ feelings about the importance of religion and their longer,
disability-free life expectancies.
Attending religious services not only enables older adults to maintain
and practice their faith but provides opportunities for activity and social
contact. As part of their assessment, nurses should ask about older adults’
attendance at religious services, along with obstacles that could interfere
with their continued attendance (e.g., no longer driving, moving to a new
community, experiencing new hearing or vision problems). Nurses can offer
assistance to enable them to initiate or maintain their desired attendance at
religious services, such as helping them to arrange transportation, to locate
a compatible faith community within their new neighborhood, to connect
them with a representative from a faith community, or to obtain an assistive
device to facilitate their mobility. The value to older adults of remaining
engaged in religious services should not be underestimated; they could
potentially gain similar benefits to those of some medical treatments in
terms of extra years of disability-free living.
PRACTICE REALITIES
Mr. Brewer, 68 years old, has been in the shock trauma unit of the hospital
for a critical condition for several weeks following a serious automobile
accident. At admission, his family stated that Mr. Brewer was an atheist.
Mr. Brewer slips in and out of periods of consciousness. On several
occasions during his conscious states, he has talked about God and made
comments such as, “I hope God forgives me for rejecting him so many
years” and “I don’t want to die without getting right with God.”
The nurse who regularly cares for Mr. Brewer mentions this to Mrs.
Brewer, who is also an atheist, and asks if she thinks it would be useful to
have a member of the hospital’s clergy staff talk with her husband. Mrs.
Brewer strongly objects, stating “I don’t know who has been putting these
crazy ideas in his head and I surely am not going to allow some religious
nut to take advantage of my husband.” When Mr. Brewer speaks of God in
his wife’s presence she says, “Tom, you’ve always been too intelligent for
that crutch, so stop talking foolishly.”
There is a strong likelihood that Mr. Brewer is not going to survive.
What should the nurse do?

1. Why may spirituality become increasingly important to people as they
age?
2. Describe the ways in which spiritual needs can be difficult for older
adults to meet.
3. What questions could you ask an older adult to assess his or her
spiritual beliefs and needs?
4. Consider the older adult who is a patient in a hospital or a resident of a
long-term care facility. What opportunities exist for that person to have
periods of solitude? What could you do to facilitate periods of
solitude?
5. How can the mystery inherent in life events foster spirituality?
Chapter Summary
People are spiritual beings; therefore, spiritual care must be an integral
component of comprehensive, holistic care. Realizing their connection to
something greater than themselves—other people, nature, the universe, and
a supreme being—empowers older persons to rise above their physical,
intellectual, emotional, and social challenges and discover the peace and
harmony that facilitates healing and well-being.
Spirituality and religion are not synonymous. Spirituality is the essence
of our being that transcends and connects us to the Divine and other living
organisms. It involves relationships and feelings. Religion consists of
human-created structures, rituals, sym bolism, and rules for relating to the
Divine. Spiritual needs include love, purpose, hope, dignity, forgiveness,
gratitude, transcendence, and faith.
Spiritual assessment should explore faith beliefs and practices,
affiliation with a faith community, and the extent to which spiritual needs
are satisfied. Comments and observable signs indicating unfulfilled spiritual
needs should be noted during the assessment.
Nurses honor patients’ spiritual needs by being available to offer
support and opportunities for patients to express their feelings, respecting
patients’ beliefs, providing opportunities for patients to express their faith,
promoting hope, and assisting patients to discover meaning in challenging
situations that they face—and, if not in conflict with nurses’ personal
beliefs, praying with or for patients.
Online Resources
BeliefNet
http://www.beliefnet.com
Center for Spirituality, Theology, and Health
https://spiritualityandhealth.duke.edu
George Washington Institute for Spirituality and Health
http://www.gwish.org
Health Ministries Association
http://www.hmassoc.org
Nurses Christian Fellowship International
http://www.ncfi.org
References
Choi, S. A., & Hastings, J. F. (2018). Religion, spirituality, coping, and resilience among African
Americans with diabetes. Journal of Religion and Spirituality in Social Work , 38 (1), 93–114.
Malone, J., & Dadswell, A. (2018). The role of religion, spirituality, and/or belief in positive ageing
for older adults. Geriatrics , 3 (2). Retrieved February 20, 2020 from
Ofstedal, M. B., Chiu, C. T., Jagger, C., Saito, Y., & Zimmer, Z. (2019). Religion, life expectancy,
and disability-free life expectancy among older women and men in the United States. The
Journals of Gerontology. Series B, Psychological Sciences and Social Sciences , 74 (8), 107–
118.
CHAPTER 31
Sexuality and Intimacy
CHAPTER OUTLINE
Attitudes Toward Sex and Older Adults
Realities of Sex in Older Adulthood
Intimacy
Menopause as a Journey to Inner Connection
Self-Acceptance
Andropause
Identifying Barriers to Sexual Activity
Medical Conditions
Promoting Healthy Sexual Function
LEARNING OBJECTIVES
1. Discuss the effects of societal attitudes toward sex and older adults.
2. Explain the effects of aging on sexuality and sexual function.
3. Identify measures to manage menopausal symptoms.
4. Describe factors that can contribute to sexual dysfunction.
5. Describe ways nurses can promote healthy sexual function in older
adults.
TERMS TO KNOW
Andropausea decline in testosterone levels with aging
Dyspareuniapainful intercourse
Erectile dysfunctionthe inability to attain and maintain an erection of the
penis sufficient to engage in sexual intercourse
Hormone replacement therapy (HRT)replacement of estrogen and/or
progestin hormone that is no longer being made by the body
Menopausethe permanent cessation of menses for at least 1 year
Perimenopausethe several years prior to the onset of menopause
Postmenopausetime beginning 12 months after the last menstrual cycle
ATTITUDES TOWARD SEX AND

OLDER ADULTS
For many years, sex was a major conversational taboo in the United States.
Discussion and education concerning this natural, normal process were
discouraged and avoided in most circles. Literature on the subject was
minimal and usually secured under lock and key. An interest in sex was
considered sinful and highly improper. Although people were aware that
sexual intercourse had more than a procreative function, the other benefits
of this activity were seldom openly shared; society viewed sexual
expression outside of wedlock as disgraceful and indecent. The reluctance
to accept and intelligently confront human sexuality led to the propagation
of numerous myths, the persistence of ignorance and prejudice, and the
relegation of sex to a vulgar status.
Fortunately, attitudes have changed over the years, and sexuality has
come to be increasingly understood and appreciated. Education has helped
erase the mysteries of sex for both adults and children, and magazines,
books, television shows, and Web sites on the topic flourish. Sex courses,
workshops, and counselors throughout the country are helping people gain
greater insight about and enjoyment of sex. Not only has the stigma
attached to premarital sex been greatly reduced but also increasing numbers
of unmarried couples are living together with society’s acceptance. Sex is
now viewed as a natural, good, and beautiful shared experience.
However, “natural,” “good,” and “beautiful” are terms seldom used to
describe the sexual experiences of older individuals. When the topic of sex
and older adults is confronted, much ignorance and prejudice concerning
sex reappear. Education about the sexuality of old age is minimal; literature
abounds on the sexuality of all individuals in society with minimal attention
to older individuals. Any signs of interest in sex or open discussions of sex
by older persons are often mocked, discouraged, or viewed suspiciously.
The same criteria that make a man a “playboy” at 30 years of age make him
a “dirty old man” at 70 years of age. Unmarried young and middle-aged
adults who engage in pleasurable sexual experiences are accepted, but
widowed grandparents seeking the same enjoyment frequently elicit
disbelief and ridicule.
POINT TO PONDER
How comfortable are you acknowledging that your older relatives could
be sexually active?
Myths about older adults and sex run rampant. How many times do we
hear that women lose all desire for sex after menopause, that older men
cannot achieve an erection, and that older people are not interested in sex?
Respect for older adults as vital, sexual beings is minimized by the lack of
privacy afforded to them, by the lack of credence given to their sexuality,
and by the lack of acceptance, respect, and dignity granted to their
continued sexual expression. The myths, ignorance, and vulgar status
previously associated with sex in general have been conferred on the
sexuality of the older population. Such misconceptions and prejudices are
an injustice to persons of all ages. They reinforce any fears and aversion the
young have to growing old. They impose conformity on older adults,
requiring that they either forfeit warm and meaningful sexual experiences
or suffer feelings of guilt and abnormality.
One consequence of myths about sex in older adulthood is that older
adults may not receive respect as sexual beings. Nurses may witness subtle
or blatant violations of respect to older adults’ sexual identity such as the
following:
elittling older adults’ interest in clothing, cosmetics, and hairstyles

B
Dressing men and women residents of a nursing home in similar
asexual clothing
Denying a woman’s request for a female aide to bathe her
Forgetting to button, zip, or fasten clothing when dressing older
persons
Unnecessarily exposing older individuals during examination or care
activities
Discussing incontinent episodes when the involved individual’s peers
are present
Ignoring a man’s desire to be cleaned and shaved before his female
friend visits
Ignoring attempts by older adults to look attractive
Not considering that an older adult’s spouse or partner can be of the
same sex
Joking about two senior citizens’ interest in and flirtation with each
other
These examples demonstrate a lack of understanding of the fact that it is

important to recognize and respect the sexual identity of any individual,
regardless of age. It is not unusual for a 30-year-old to be interested in the
latest fashions, for two 35-year-olds to be dating, or for a 20-year-old
woman to prefer a female gynecologist. Almost any young woman would
not want a new date to see her before she has had time to adjust her
cosmetics, hair, and clothing. No care provider would walk into the room of
a 25-year-old in traction and undress and bathe him in full view of other
people in the room. Older adults are entitled to the same dignity and respect
as sexual human beings that are afforded to persons of other ages.
POINT TO PONDER
What attitudes toward sex and older adults do you hold? What
contributed to the formation of these attitudes?
An additional consequence of stereotypical views toward sex in late life

is that issues pertaining to safe sex among senior adults are often ignored.
The incidence of acquired immunodeficiency syndrome (AIDS) has
increased more than twice as quickly in people over age 50 than in younger
adults, and this older population accounts for one in six human
immunodeficiency virus (HIV)/AIDS diagnoses in the United States
(Centers for Disease Control and Prevention, 2019). Most older men who
have HIV contracted it through sex with another male, whereas most older
women who are infected became so through heterosexual contact. Sexually
active older persons who have sex with new or multiple partners may not
consider using a condom because pregnancy is no longer a risk; they may
also have misconceptions about sexually transmitted diseases, believing that
these diseases only affect younger persons. If they do become symptomatic
or learn that a sexual partner is HIV positive, older adults may be
embarrassed to seek medical attention; they also often attribute the
symptoms to normal aging. If they do present with symptoms to a provider,
the provider may not associate the symptoms with HIV simply because the
person is old (e.g., HIV-related dementia can be misdiagnosed as
Alzheimer’s disease). These factors contribute to HIV usually being
diagnosed in a later stage in older persons. It is important for nurses to
reinforce safe sex practices to older persons and to ask about safe sex
practices and risk factors for HIV during the assessment.
Nurses can play a significant role in educating and counseling about
sexuality in late life; they can encourage attitude changes by their own
examples.
REALITIES OF SEX IN OLDER

ADULTHOOD
Until the work by Kinsey (1948) and Masters and Johnson (1966), there had
been minimal exploration into the realities of sex in old age. Several
possible factors have contributed to this lack of research and information.
One is the acceptance and expansion of sexology that has occurred within
the past few decades. Another is that impropriety was formerly associated
with open discussions of sex. Furthermore, there was a misconception on
the part of many professionals, older people, and the general public that
older individuals are neither interested in nor capable of sex. In addition,
practitioners lacked experience in and did not have an inclination toward
discussing sex with any age group. Even today, medical and nursing
assessments frequently do not reflect inquiry into sexual history and
activity.
Nurses should be aware of recent interest and research in the area of sex
in late life and communicate these research findings to colleagues and
clients to promote a more realistic understanding of the older population’s
sexuality.

Research, reinforced by creative advertisements for erectile dysfunction
drugs, has disproved the belief that older persons are not interested in or
capable of engaging in sex; older adults can and do enjoy the pleasures of
sexual foreplay and intercourse. Because the general pattern of sexual
behavior is basically consistent throughout the life, individuals who were
disinterested in sex and had infrequent intercourse throughout their lifetime
will not usually develop a sudden insatiable desire for sex in old age.
Similarly, a couple who has maintained an interest in sex and continued
regular coitus throughout their adult life will most likely not forfeit this
activity at any particular age. Homosexuality, masturbation, a desire for a
variety of sexual partners, and other sexual patterns also continue into old
age. Sexual styles, interests, and expression must be viewed in the context
of the individual’s total life experience.
The same is true for identification with sexual roles. Perceptions of
male and female roles have changed over time. Many of today’s older
population were socialized to accept certain masculine and feminine roles—
older individuals have had a lifetime of experience with the expectation that
men are to be aggressive, independent, and strong and that women are to be
pretty, gentle, and dependent on their male counterparts. The baby boomers
changed those views as the women’s liberation movement encouraged
women to be independent, strong, and on equal terms with men in the home
and workplace. In addition, there was an acceptance and expectation that
men should share household and family nurturing responsibilities that once
were thought to be within the realm of women. The result is diversity in sex
role identity and expectations among the older population. Such differences,
based on socialization and decades of living, need to be recognized and
respected.
Intimacy
Sexuality also encompasses much more than physical acts. It includes love,
warmth, caring, and sharing between individuals; seeing beyond gray hair,
wrinkles, and other manifestations of aging; and the intimate exchange of
words and touches by sexual human beings. Feeling important to and
wanted by another person promotes security, comfort, and emotional well-
being (Fig. 31-1). With the multiple losses that older adults experience, the
comfort and satisfaction derived from a meaningful relationship are
especially significant.
FIGURE 31-1 In addition to physical means of
expression, older adults express their sexuality
emotionally in intimate relationships.
KEY CONCEPT
Sexuality includes love, warmth, caring, and sharing between people and
identification with a sexual role.

Despite the physical ability to remain sexually active in old age, various
factors and age-related changes do impact the older person’s sexual
function. Although clinical data are minimal and additional research is
necessary, some general statements can be made about sex and the older
person:
There is a decrease in sexual responsiveness and a reduction in the

frequency of orgasm (Masters & Johnson, 1981; Mitchell & Waetjen,
2018).
Older men are slower to erect, mount, and ejaculate.
Older women may experience dyspareunia (painful intercourse) as a
result of less lubrication, decreased distensibility, and thinning of the
vaginal walls.
Many older women gain a new interest in sex, possibly because they
no longer have to fear an unwanted pregnancy or because they have
more time and privacy with their children grown and gone.

Note that premature ejaculation is not an age-related change. Premature
ejaculation occurs when ejaculation occurs before or just after penetration
of the vagina by the penis. Older adult men are slower to ejaculate than
younger men.
Although individual differences occur in the intensity and duration of

sexual response in older people, regular sexual expression for both sexes is
important in promoting sexual capacity and maintaining sexual function.
With good health and the availability of a partner, sexual activity can
continue well into the seventh decade and beyond. The frequency of sexual
activity may decrease, but that is not necessarily accompanied by a
reduction in sexual interest or ability.
The work of Masters and Johnson (1966) provided the first major
insight into the sexual responses of older persons. Table 31-1 summarizes
their findings.
TABLE 31-1 Human Sexual Response Cycle in Late Life

MENOPAUSE AS A JOURNEY TO
INNER CONNECTION
Menopause , the permanent cessation of menses for at least 1 year, occurs
for most women around the fifth decade of life. Some individuals view
menopause as a time of experiencing and managing hormonal changes. In
fact, to some extent, menopause has been “medicalized” because it is
considered a problem or condition that must be treated. Although there are
real physiological concerns to consider, menopause is broader in scope than
merely a physiological experience. It is a time of important transition in a
woman’s life that can result in an awakening of a new wholeness of body,
mind, and spirit. By the time the average woman reaches menopause, she
has considerable life experience that has afforded her a special wisdom.
Many cultures honor the wisdom gleaned from years of living and seek the
guidance of older adults. Unfortunately, Western society tends to prize the
physical beauty of youth over the inner beauty of age. Women in their 50s,
60s, and beyond can feel unattractive, unappreciated, and underutilized as a
result.
KEY CONCEPT
Menopause marks the entry into a new season of life, characterized by
wisdom and groundedness.
With a generation of baby boomers—who are redefining the norms for

aging—experiencing or about to experience menopause, an enlightened
view of menopause is emerging. This generation of assertive, proactive
women does not wish to be confined to limited roles based on physical
characteristics. They desire and demand that their talents be used and that
they have opportunities for continued growth. The wonder and wisdom of
age may receive a long-deserved place of importance.

Effective management of the physical aspects of menopause can enable
women to experience this season of life as a positive passage rather than as
a distressing detour. Gerontological nurses can serve older women well by
being knowledgeable about menopause and helping women separate myths
from realities about this life transition.
Menopause occurs when estrogen levels fall and the reduced number of
ovarian follicles lose their ability to respond to gonadotropic hormone
stimulation. Before menopause, the main source of estrogen is estradiol,
which is produced by the ovaries. When the ovaries decline in function,
most estrogen is obtained through the conversion of androstenedione to
estrone in the skin and adipose tissue. A variety of factors can cause
estrogen levels to vary among postmenopausal women. Box 31-1 lists
symptoms that may be associated with estrogen loss.
BOX 31-1 Symptoms Associated With

Menopause
Physical Symptoms
Hot flashes
Fatigue
New onset of migraines
Symptoms of arthritis, fibromyalgia
Heart palpitations, atypical angina
Restless leg syndrome
Vaginal dryness, itchiness
Loss of subcutaneous fat in labia
Insomnia
Decreased metabolic rate, weight gain
Increased fat on stomach and hips
Lower urinary tract symptoms (urinary frequency, stress
incontinence, urgency, and nighttime voiding)
Bladder and vaginal infections
Increased risks of osteoporosis, heart disease, and colon cancer
Emotional/Cognitive Symptoms
Moodiness
Depression
Memory problems
Fuzzy thinking
Lack of concentration
Lower tolerance for annoyance
Quick to anger
Greater impatience
Anxiety, restlessness, new onset of panic disorder
Paranoia, psychotic symptoms
It has long been known that hormone therapy can reduce symptoms
associated with menopause; however, the issues of risks and benefits for
various women have been less clear. In 1991, the National Institutes of
Health (NIH) launched the Women’s Health Initiative, which studied the
effects of hormones in more than 27,000 women. In 2002, NIH stopped the
part of the study in which women received estrogen and progestin due to
findings that these women experienced higher heart risks; the portion of the
study in which women received only estrogen continued. Concerned about
their risks, many women discontinued hormone replacement therapy (HRT)
when the study results were announced. A variety of studies surfaced
thereafter stating that women who started HRT within 10 years of
menopause appeared to have a lower risk of heart attack and breast cancer,
whereas women who began taking hormones 10 or more years past
menopause had a significantly higher risk of heart problems, suggesting the
age at which therapy is initiated affected risks. Although preliminary
research indicates that HRT may reduce the risk of diabetes, this therapy is
currently not recommended for this purpose because it could increase the
risk of blood clots, stroke, and coronary artery disease (Cobin & Goodman,
2017).
The current guidelines from the North American Menopause Society
(2017) offer different recommendations for estrogen–progestogen therapy
(EPT) and estrogen therapy (ET) than what have been suggested in the past
and conclude that HRT:
Should be individualized based on the woman’s age, time since

menopause, personal health risks, and potential risks and benefits
Is most effective for treating vasomotor symptoms and genitourinary
syndrome of menopause
Is effective in preventing bone loss and fracture
Has a favorable risk–benefit ratio for women under age 60 years who
are within 10 years of menopause and have no conditions that would
contraindicate therapy
Has a less favorable risk–benefit ratio for when aged 60 years and
older who initiate therapy more than 10 or 20 years from menopause
onset
KEY CONCEPT
The benefits and risks associated with HRT depend on the age at which a
woman starts therapy and her unique health profile, requiring that HRT
be individualized.
The use of bioidentical, custom-compounded hormones is not

recommended. There is some evidence that herbs may aid in modest
reductions in hot flashes and vaginal dryness, but the lack of a consistent
quality of these products causes more research to be needed regarding the
use of plant-based and natural therapies (Franco et al., 2016; Johnson,
Roberts, & Elkins, 2019).
In addition to HRT, natural and alternative therapies for managing
symptoms are available (Box 31-2). The effectiveness of these therapies
varies among women.
BOX 31-2 Complementary and Alternative

Approaches to Aid in Controlling Menopausal
Symptoms
Acupuncture
Diet:
Foods rich in plant estrogens: apples, beans, carrots, celery,
nuts, seeds, soy products (approximately 100 to 160 mg/d of
soy is needed to obtain significant relief), wheat, and whole
grains
Foods rich in boron to increase estrogen retention: asparagus,
beans, broccoli, cabbage, peaches, prunes, strawberries, and
tomatoes
Avoidance of adrenal-stimulating foods: alcohol, caffeine,
refined carbohydrates, salt, and sugar
Exercise
Imagery
Meditation
Regular, adequate sleep
Stress management practices
T’ai chi
Vaginal moisturizing agents:
Commercial vaginal moisturizing creams (e.g., Replens),
water-based gels
Herbal salves made with marshmallow root, calendula
blossom, comfrey, licorice root, and wild yam
St. John’s wort oil
Vitamins and minerals such as calcium, chromium, magnesium,
selenium, and vitamins C, D, and E
Yoga
Middle-aged women can benefit from basic education about menopause

and methods for managing symptoms. Box 31-3 outlines some of the major
topics that could be included in a menopausal educational program.
BOX 31-3 Topics for Inclusion in a Menopause

Education Program
Menopause is a naturally occurring process, not a disease. It is
characterized by the absence of menstrual periods for at least 12
consecutive months.
Menopause is a gradual process. Most women experience
perimenopause about 3 to 6 years before menopause when
menstrual periods permanently cease. By age 40, most women
begin having irregular periods.
Menopause is a multihormone process. In addition to estrogen,
progesterone declines although not in a direct proportion. In fact,
some of the symptoms associated with menopause can be the result
of declining progesterone with estrogen dominance. One outcome
of estrogen dominance over progesterone is the blocking of the
action of thyroid hormone. Although it does not occur in all
menopausal women, some can have declines in testosterone, which
affects libido and sexual pleasure. Factors such as stress and obesity
affect the hormonal secretion.
Estrogen affects functions beyond those of reproduction. Estrogen:
Increases the chemical enzyme choline acetyltransferase
needed to synthesize
The neurotransmitter acetylcholine (which is critical for
memory)
Promotes the growth of dendritic spines on neurons
Enhances the availability of the neurotransmitters serotonin,
norepinephrine, and dopamine
Acts like an antioxidant to protect nerve cells from free radical
damage
Many physical, cognitive, and emotional symptoms can be
associated with low estrogen levels (see Box 31-1).
Diagnostic blood tests should be done to properly assess the
menopausal state; these include follicle-stimulating hormone
(FSH), luteinizing hormone (LH), estradiol (estrogen), testosterone,
and free testosterone levels. If sexual dysfunction or low libido is
present, evaluate thyroid function (T3, T4, free T4, and TSH),
platelet monoamine oxidase, and prolactin.
Hormonal replacement therapy (HRT) carries the risks and benefits
that must be weighed for each individual.
Complementary therapies and practices can assist in controlling
symptoms in some women (see Box 31-2).
Self-Acceptance
Nurses can help women appreciate menopause as a time to take stock and
rechart their life course. Women can unleash creative energies and discover
new interests. They can realize the significance of caring for and nurturing
self. Whether it is their maturation or a desire to not waste the precious
limited time one has remaining in life, older adults tend to understand
themselves and their lives. Impossible expectations and pretense can be let
go, unleashing more meaningful and creative aspects of later life. Older
individuals can live in truth and love as who they truly are. This self-
acceptance can provide the security to broaden their perspectives and
purposes and deepen their connections with others and a higher power.
POINT TO PONDER
Do you view menopause as a time marking the loss of youthfulness and
beauty, or the beginning of a journey into new creativity and wisdom?
What has influenced your opinion?
Andropause
Women are not the only ones to experience hormonal changes with age.
Some men experience a decline in testosterone levels, known as
andropause , which begins around the third decade of life or later. It differs
from menopause in that it does not occur in all men, and when it does occur,
it is a slower process. The likelihood of developing andropause increases
with age. Unlike women, whose bodies eventually cease production of
estrogen, the testes normally do not lose their ability to make testosterone.
When testosterone levels fall to low levels, the body increases the
production of FSH and LH in an effort to increase testosterone.
Low testosterone levels in older men can result in reduced muscle mass,
energy, strength, and stamina. Erectile dysfunction can occur, along with
breast enlargement, osteopenia, osteoporosis, shrinkage of the testes, and
reduced libido. Emotional and cognitive changes can also occur. The low
testosterone levels are not only associated with reduced sexual function but
also a higher risk for chronic renal disease and type 2 diabetes (Amiri et al.,
2019; Kirby, Hackett, & Ramachandran, 2019). Recent studies have
disproved earlier ones regarding the relationship of low testosterone levels
to coronary heart disease (Zeller et al., 2019). Again, it is important to
recognize that low testosterone levels are not a normal occurrence in all
aging men. Androgen replacement therapy can be prescribed, but it does
carry potential side effects and risks, such as fluid retention, sleep disorders,
breast enlargement or tenderness, and prostate growth; it is not
recommended for men with a history of prostate or breast cancer.
IDENTIFYING BARRIERS TO SEXUAL
ACTIVITY
In addition to the impact of age-related changes, various physical,
emotional, and social variables can threaten the older person’s ability to
remain sexually active (Table 31-2 and Nursing Problem Highlight 31-1). A
comprehensive nursing assessment includes a sexual history, which can
reveal these problems. Assessment Guide 31-1 offers sample questions that
can be incorporated into the assessment to identify issues pertaining to
sexual function. Sensitive attention to the maintenance of sexual function
and identity is significant in promoting wellness.
TABLE 31-2 Potential Nursing Problems Related to Sexuality

That Result From Aging

PROBLEM ACHIEVING SEXUAL
FULFILLMENT
Overview
Problem achieving sexual fulfillment indicates an inability to derive sexual
satisfaction. This condition can be identified through the patient’s history
(e.g., complaints of impotence, dyspareunia, lack of interest in sex, and
changes in relationship with partner), physical findings (e.g., genital
infection, prolapsed uterus, and diabetes mellitus), or behavior (e.g.,
depression, anxiety, and self-deprecation). Sometimes, changes in the
older person’s life can give clues to the presence of sexual dysfunction
problems, such as recent widowhood, onset of a new health problem, or
moving to a child’s home.
Age-related dryness and fragility of vaginal canal, vaginal infection,
venereal disease, neurological disease, cardiovascular disease, diabetes
mellitus, decreased hormone production, pulmonary disease, arthritis,
pain, prostatitis, prolapsed uterus, cystocele, rectocele, medications,
overeating, obesity, fatigue, alcohol consumption, fear of worsening health
problem, lack of partner, unwilling or unable partner, boredom with
partner, fear of failure, guilt, anxiety, depression, stress, negative self-
concept, lack of privacy, religious conflict, and altered appearance.
Goal
The patient expresses satisfaction with sexual function.
Interventions
Obtain a sexual history from the older adult. Note the availability and
quality of relationship with partner, lifelong pattern of sexual
function, recent changes to sexual function, signs and symptoms of
sexual dysfunction, knowledge and attitudes about sex, medical
problems, drugs used, mental status, myths and misinformation, and
feelings about sexual dysfunction.
If the cause of sexual dysfunction is not readily available through the
history, refer the older person for a comprehensive physical
examination.
Identify causative or contributing factors to sexual dysfunction and
plan interventions to correct them.
Refer to sexual counselor or therapist as needed.
Clarify misconceptions (e.g., a person cannot have sex after a heart
attack).
Provide education as to normal sexual function, measures to promote
sexual function, and how to minimize impact of health problems on
sexual function. (The American Heart Association, the Arthritis
Foundation, and other disease-specific organizations provide
literature on promoting sexual function in the presence of disease.)
Assist the older adult in having a good appearance and improving
self-concept as needed.
Advise in health practices that will promote sexual function, such as
regular gynecologic examinations, alcohol use in moderation, good
diet, and exercise.
Ensure staff are nonjudgmental about the older adult’s unique means
of sexual expression.
If the older adult is hospitalized or institutionalized, provide privacy
for sexual expression.

SEXUAL HEALTH
INTERVIEW
Begin this component of the overall assessment by explaining to the older
adult that you are going to ask questions pertaining to his or her sex life to
identify problems that could be improved and to learn about possible
underlying conditions that could be revealed through sexual problems.
Ask the older adult for permission to ask these questions:
Are you sexually active?
If the answer is no, ask for reasons (e.g., no partner, not enough
energy, and erectile dysfunction). Based on the reason, inquire about the
older adult’s interest in changing the situation to become sexually active
and recommend plans accordingly (e.g., offer location of senior centers,
evaluate possible causes of low energy, and refer to sexual dysfunction
clinic).
If the answer is yes, proceed with the following questions:
How frequently do you have sex? Is this a satisfying frequency to

you? If not, how would you change the frequency of sex?
Do you have sex with a single or multiple partners? Male or female
partner?
If you have sex with new partners, do you use a condom?
Do you obtain pleasure from sex? If not, why not?
Have you or your partner(s) ever been treated for a sexually
transmitted infection? If yes, for what disease and when?
Do you or your partner(s) have risk factors for HIV/AIDS, such as a
history of blood transfusions, IV drug use, or sex with multiple
partners or prostitutes?
Male: Are you able to get an erection when you want to engage in
sex? Do you have orgasms and ejaculate when you have sex? If not,
describe what happens. Do you have any sores on your penis or any
discharge?
Female: Is sex comfortable for you? If not, describe. Do you have
orgasms? Do you have any vaginal discharge or bleeding?
Is your partner satisfied with your sex life? If not, why not?
Have you ever been or are you currently being sexually abused?
Raped? If yes, describe.
If health conditions or disabilities are present: How has your
condition affected your ability to enjoy sex?
What concerns do you have regarding your sex life?
Do you have any questions about your sexual function that you would
like me to answer?
LABORATORY TESTS
A variety of laboratory tests can aid in identifying changes in hormone
levels that can affect sexual function; these include the following:
Complete blood count

Complete metabolic panel
Dihydrotestosterone
Estradiol
Mean gonadotropin-releasing hormone
Prostate-specific antigen
Serum prolactin
Thyroid-stimulating hormone (TSH)
Total serum testosterone
MEDICATIONS
A review of the prescription and over-the-counter drugs used is beneficial
in identifying the relationship of medications to any sexual problems. Pay
particular attention to the use of angiotensin-converting enzyme (ACE)
inhibitors, alcohol, α-adrenergic blockers, antianxieties/benzodiazepines,
anticholinergics, antidepressants, antihistamines, antihypertensives,
antiparkinsonian agents, diuretics, dopamine agonists, monoamine oxidase
inhibitors (MAOIs), nicotine, nonsteroid anti-inflammatory drugs,
sedatives/hypnotics, and recreational drugs.
DIAGNOSES
Review the medical history for health conditions that could interfere with
sexual function (see Table 31-3).
TABLE 31-3 Medical Conditions Interfering With Sexual

Function
COMMUNICATION TIP
Some older persons may be uncomfortable discussing sex, particularly
with a nurse who is young enough to be their daughter or
granddaughter. To put the person at ease, address the topic in a matter-
of-fact way. It can be beneficial to introduce the topic with comments
such as: “I’m going to ask you some questions about your sexual
activity because this can not only help us to improve any problems
that may exist but also identify health conditions that can show
symptoms through sexual function problem.”
KEY CONCEPT
The unavailability of a partner, ageism, changes in body image,
boredom, misconceptions, physical conditions, medications, and
cognitive impairments are among the factors that can interfere with
sexual fulfillment in later life.
A practical interference with sexual fulfillment in later life is the lack of a
partner, particularly for older women. By 65 years of age, there are only 7
men to every 10 women; by 85 years of age, the ratio becomes 1:2.
Furthermore, there is a tendency for men to marry women who are younger
than themselves; one third of men older than 65 years of age have wives
younger than 65 years of age. Therefore, most older men are married, and
most older women are widowed.
Even when an older person has a spouse or partner, that person may be
too infirm to remain sexually active and, in some cases, may be
institutionalized.
Sometimes, sexual dysfunction can have psychological causes. Negative
attitudes from society, fear of losing sexual abilities, concerns about body
image, relationship issues, and misconceptions held by older adults
themselves can impair sexual function.
Older adults are not immune to the attitudes around them. As they hear
comments about the inappropriateness of older people engaging in sex and
watch television shows that portray sex among older individuals in a
condescending or ridiculing manner, they may feel foolish or unnatural in
having sexual desires and activity. If they happen to have sexual partners
who are disinterested in sex and negatively label their advances, the
problem is intensified. As older adults internalize others’ reactions, they
may become reluctant or unable to engage in sexual activity and
unnecessarily forfeit sexual function. Nurses can advocate for older adults
by educating persons of all ages in the realities and importance of sexual
function in later life and ensuring that nursing care does not reinforce
negative attitudes about sex.
Problems may also occur when the older man believes he is losing his
sexual capability, even when he is not. It is not unusual for older men to
occasionally have difficulty achieving an erection; erections also may be
easily lost if there is an interruption (e.g., a ringing telephone or a partner
who leaves the bed to use the bathroom). These occurrences can trigger a
cycle of problems, whereby an episode of impotence causes anxiety over
the potential loss of sexual function permanently, and this anxiety interferes
with the ability to become erect, which further heightens anxiety. Aging
persons need realistic explanations—preferably before the situation arises—
that occasional impotence is neither unusual nor an indication that one is
“too old for sex.” Open discussions and reassurance are beneficial. The
partner needs to be included in this process and made aware of the
importance of patience and sensitivity in helping the man deal with this
problem. The couple should be encouraged to continue their efforts and, if
erection is occasionally a problem, compensate with other forms of sexual
gratification. Of course, chronic impotence can indicate a variety of
disorders and deserves a thorough evaluation.
Body image and self-concept affect sexual activity. In a society in
which beauty is youthful, older persons may believe that their wrinkles,
gray hair, and sagging torsos make them physically unappealing. This can
be particularly difficult for single older people who must deal with baring
their bodies to new partners. The fear of being unattractive and rejected
may cause older adults to avoid encountering such situations and assume a
sexually inactive role.
Additional factors make developing a sexual relationship difficult for
single older people. Older women were socialized during a period when sex
was considered appropriate only in wedlock and, for some persons, only for
the purpose of procreation. The thought of seeking sexual gratification with
a partner to whom one is not married creates anxiety and guilt in many
older women. The older man, who was socialized in the aggressor role, may
not have had to practice his courtship skills for years if he has been
monogamous for a long period, and he may feel insecure in his ability to
seduce a partner or find one who understands his individual preferences.
He, too, may be emotionally uncomfortable in establishing a sexual
relationship. Financial considerations can affect sexual activity also when
the single older adult has concern that commitment to a relationship and
marriage could reduce Social Security Income or create problems in sharing
assets. The hurdle of building new sexual relationships can be so great that
many older people may find it easier to repress their sexual needs.
KEY CONCEPT
Some older adults may repress sexual needs rather than confront the
stresses associated with establishing new sexual relationships.
CONSIDER THIS CASE

Seventy-two-year-old Mrs. W has been
widowed for 8 months. She is an attractive, active woman who desired to
break up her lonely days by joining a local senior center, where she met
Mr. R, a handsome 75-year-old widower. In short time, they began dating,
and recently, Mr. R has asked Mrs. W to join him for a long weekend at a
romantic vacation spot. Mr. R has openly shared that he has had frequent
sexual partners and that he envisions initiating a sexual relationship with
Mrs. W during their weekend.
Mrs. W is interested in taking the relationship to this new level but is
nervous about the fact that she and her husband did not have intercourse
during the last 8 years of his life due to his poor health, and she now
wonders how much discomfort she will experience. She discusses this
with a nurse friend and expresses concerns about having a new sexual
partner for the first time in over 50 years, Mr. R’s possible reactions to
seeing her “naked old body,” and what her children and grandchildren
would think if they found out about her weekend.
THINK CRITICALLY
1. What advice would be helpful for the nurse friend to offer?
2. What are some of the challenges and risks that Mrs. W could
face?
Married older people also may experience problems with sex. Not all
marriages enjoy fulfilling sex. Some women conceded to sex because it was
a “wife’s duty,” yet they never achieved satisfaction from this intimate
experience. Some spouses may have become bored with the same partner or
form of sex. Perhaps physical changes or an inattention to appearance
causes dissatisfaction with the partner. Love and caring may have been lost
from the marriage. Sexual interest may be diminished if one is the caregiver
for a partner or if a disability causes the partner to be perceived as sexually
undesirable. Older couples experience sexual problems for many of the
same reasons that younger couples do.
Misconceptions are often responsible for creating obstacles to a
fulfilling sex life in old age and can include the following:
Erections are not possible after prostatectomy.

Penile penetration can be harmful to a woman after a hysterectomy.
Menopause eliminates sexual desire.
Sex is bad for a heart condition.
After a hip fracture, intercourse can refracture the bone.
Sexual ability and interest are lost with age.
Straightforward explanations and public education can help correct

these misconceptions, as can realistic descriptions of how illness, surgery,
and drugs do and do not affect sexual function.
Medical Conditions
A variety of physical conditions, many of which respond to treatment
(Table 31-3), can affect sexual function in later life. A thorough evaluation
is crucial in determining a realistic approach to aiding older adults with
these problems. Interventions that are of value to younger people also can
benefit older people, including medications, penile prostheses, lubricants,
surgery, and sex counseling. Nurses should communicate their
understanding of the importance of sexual functioning to older adults and a
willingness to assist them in preserving sexual capabilities.
Erectile dysfunction, commonly referred to as impotence, is a condition in
which a man is unable to attain and maintain an erection of the penis
sufficient to allow him to engage in sexual intercourse. This condition
affects as many as 40% of men between the ages of 40 and 70 years, with
an increased prevalence with age (Goldstein, Groen, Li, Tang, & Hassan,
2020). Erectile dysfunction can have multiple causes, including
atherosclerosis, diabetes, hypertension, multiple sclerosis, thyroid
dysfunction, alcoholism, renal failure, structure abnormalities (e.g.,
Peyronie’s disease), medications, and psychological factors. With the range
and complexity of potential causes, a thorough physical examination is
essential. (Even if the older man is not interested in being sexually active,
he should be encouraged to have this dysfunction evaluated to identify
underlying conditions that warrant medical attention.)
In 1998, a major breakthrough occurred in the treatment of erectile
dysfunction with the Food and Drug Administration’s approval of sildenafil
citrate (Viagra). Within its first year on the market, nearly 4 million
prescriptions were written for Viagra, demonstrating the scope of erectile
dysfunction and the desire of men to correct this problem. Since then, other
drugs, such as tadalafil (Cialis) and vardenafil (Levitra), have become
available to treat this condition. There are other options to treat erectile
dysfunction, such as alprostadil (a drug that is injected into the penis to
increase blood flow), vacuum pumps, and penile implants. Men need to
discuss with their physicians the options that are best for them.

Frequently, medications prescribed to older people affect potency, libido,
orgasm, and ejaculation. Some of these drugs include the following:
ACE inhibitors
Alcohol
α-Adrenergic blockers
Antianxieties/benzodiazepines
Anticholinergics
Antidepressants
Antihistamines
Antihypertensives
Antiparkinsonian agents
Diuretics
Dopamine agonists
MAOIs
Nicotine
Nonsteroidal anti-inflammatories
Sedatives/hypnotics
Some recreational drugs
It is important to prepare older people for the potential changes in

sexual function that drugs can produce. Imagine what it does to a patient
with newly diagnosed hypertension when he experiences drug-related
impotency and begins to feel anxious about the sudden changes in both
health and sexual function. Drugs should be reviewed when new sexual
dysfunction occurs, and, whenever possible, nondrug treatment modalities
should be used to manage health problems.
The sexual behavior of individuals with dementia tends to be more difficult
for those around them than for the affected persons. Inappropriate behavior,
such as undressing and masturbating in public areas and grabbing and
making sexual comments to strangers, can occur. The cognitively impaired
person may accuse his or her spouse of being a stranger improperly trying
to share the bed and may misunderstand care procedures (e.g., baths and
catheterization) as sexual advances. Sometimes touching and statements
such as “How’s my sweetheart?” or “Are you going to give me a big hug?”
can be misinterpreted as invitations to become sexually intimate. Family
members and caregivers need to understand that this is a normal feature of
the illness. Rather than becoming upset or embarrassed, they need to learn
to respond simply, for example, by taking the individual to a private area
when masturbating, or stating “I’m not a stranger, I’m Mary, your wife.”
KEY CONCEPT
Unintentionally, caregivers can make comments to the cognitively
impaired person that can be misinterpreted as flirtatious and trigger
inappropriate sexual behaviors.
PROMOTING HEALTHY SEXUAL

FUNCTION
The nurse can foster sexuality and intimacy in older persons in various
ways, some of which have already been discussed. Basic education can help
older adults and persons of all ages understand the effects of the aging
process on sexuality by providing a realistic framework for sexual
functioning. The nurse can teach about sexual functioning during routine
health assessments, as part of structured health education classes, and
during discharge planning when reviewing capabilities and activity
restrictions.
A willingness on the nurse’s part to discuss sex openly with older
people demonstrates recognition, acceptance, and respect for their sexuality.
A sexual history as part of the nursing assessment provides an excellent
framework for launching such discussions. The nurse identifies physical,
emotional, and social threats to older adults’ sexuality and intimacy and
seeks solutions for problems—whether caused by the disfigurement of
surgery, obesity, depression, poor self-concept, fatigue, or lack of privacy.
The nurse can also promote practices that can enhance sexual function,
including regular exercise, good nutrition, limited alcohol intake, ample
rest, stress management, good hygiene and grooming practices, and
enjoyable foreplay.
KEY CONCEPT
The nurse’s willingness to discuss sex openly with older adults
demonstrates recognition, acceptance, and respect for their sexuality.
Consideration must be given to the sexual needs of older persons in
institutional settings. Too often, couples admitted to the same facility are
not able to share a double bed, and frequently, they are not even able to
share the same room if they require different levels of care. It is unnatural
and unfair to force a person to travel to another wing of a building to visit a
spouse who has intimately shared 40, 50, or 60 years of his or her life.
There are few or no places in most institutional settings where two such
individuals can find a place to share intimacy where they will not be
interrupted or be in full view of others. Older people in institutional settings
have a right to privacy that goes beyond lip service. They should be able to
close and lock a door, feeling secure that this action will be honored. They
should not be made to feel guilty or foolish by their expressions of love and
sexuality. Their sexuality should not be sanctioned, screened, or severed by
any other person.
Masturbation is often beneficial for releasing sexual tensions and
maintaining continued function of the genitalia. Nurses can convey their
acceptance and understanding of the value of this activity by providing
privacy and a nonjudgmental attitude. Conveying such an attitude can
prevent older individuals from developing feelings of guilt or abnormality
related to masturbation.
In addition, nurses must appreciate that sexual satisfaction can have
different meaning to older people than to the young. To some older men and
women, holding, caressing, and exchanging loving words can be as
meaningful as intercourse or sexually explicit conversation.
For older adults in any setting, nurses can facilitate connections, which
are essential for sexual relationships. Unfortunately, relationships can be
more challenging to create and sustain in late life. The circle of friends and
family gradually diminishes with each passing year; health and economic
limitations decrease one’s participation in social activities; and
preoccupation with health conditions of self and significant others narrows
one’s sphere of interests. The risks resulting in a shrinking of older adults’
social world are real and often significant; however, nurses can offer
interventions that can minimize and compensate for them. Box 31-4 offers
suggestions for helping older adults to maintain satisfying, healthy
relationships.
BOX 31-4 Strategies to Facilitate Connections
Assist patients in evaluating current relationships. Guide them in
examining relationship patterns that are effective and those that
could be improved. Discuss the impact of relationships on health
Guide patients in becoming aware of their behaviors and responses
that impact relationships. Help them to gain insight into roles and
dynamics and impact of responses.
Teach strategies that promote effective expression of inner feelings.
Offer suggestions and role plays that support feeling-based
communication, such as making statements that reflect how they
feel rather than impersonal generalities (e.g., “I feel angry when
you make my decisions for me”). Help patients to respect others’
expressions of feelings.
Provide information on sources of social activities. Obtain address
and contact information for local senior centers, clubs, and social
groups. Suggest measures that patients can use to facilitate a
comfortable entry into new groups, such as asking a friend to
accompany them, taking the lead in introductions, and finding a
common interest that can be used as a stimulus for conversation.
Refer patients for hearing and/or vision examinations as needed.
Initiate audiology and ophthalmology referrals if problems are
identified during the nursing assessment. Assist patients in locating
financial aid if costs for examinations, glasses, or aids cannot be
afforded.
Respect patients’ interest and efforts to be sexually active. Support
efforts to enhance appearance. Listen without judgment as patients
describe feelings about their sexual interests and function. Provide
privacy for patients’ interactions with significant others.
Assist patients in improving sexual function. Refer to appropriate
specialists for the treatment of conditions that affect sexual
function. Support efforts to correct sexual dysfunction. Counsel
patients in measures to preserve and facilitate sexual function (e.g.,
use of lubricating creams to compensate for vaginal dryness,
alternative positions to accommodate joint pain, and timing of
medication administration to maximize energy during sex).
Provide positive feedback for efforts patients have taken to improve
the quantity and quality of connections with others. Remember that
an action that may seem minor, such as attending a community
social event, could have required tremendous effort and risk on the
part of patients. Recognize and encourage these efforts.
Nurses’ Experiences and Reactions Toward

Intimacy and Sexuality Expressions by Nursing
Home Residents: A Qualitative Study
Source: Thys, K., Mahieu, L., Cavolo, A., Hensen, C., Dierckx de Casterte,
B., & Gastmans, C. (2019). Journal of Clinical Nursing, 28(5–6), 836–849.
Older adults do not lose their desire for sexual expression and intimacy
when they enter a nursing home; however, they often experience challenges
to their sexual well-being because they commonly perceive nurses as
having negative attitudes toward residents’ intimate and sexual expression.
This study, using a qualitative design, was done to gain insight into how
nurses experience and react to nursing home residents’ sexual expression.
Interviews with nurses from seven nursing homes were conducted.
The study found that nurses reacted to residents’ intimate and sexual
expression in individual ways based on their own comfort level, their own
sexual boundaries, and the reactions of residents’ families and other
residents. The nurses’ responses fell into three categories: active
facilitation, in which the nurses supported and assisted residents in fulfilling
their desires; tolerance, in which the nurses accepted and allowed sexual
expression but did not involve themselves in facilitating it; and termination,
in which the nurses did not allow the expression.
Allowing and facilitating nursing home residents’ sexual expression
(e.g., providing two residents privacy, transporting a resident to another part
of the facility to be with a sexual partner, allowing another resident to share
a resident’s bed) need to take several factors into consideration, such as the
competency of the resident to make the decision, the health and safety risks
of the residents engaging in sexual expression, sensitivity to other residents
who may witness the relationship, and reactions of family members. The
policy of the facility regarding these issues needs to be followed. If there is
no policy, the nurse should recommend a committee be formed to develop
one; if an existing policy seems too restrictive, the nurse can request that a
committee review it to ensure residents’ rights are respected. Consideration
also must be given to protecting residents from sexual abuse by other
residents, visitors, or staff; although competent, residents may be vulnerable
to agreeing to undesired sexual activity as a means to obtain attention or
rewards.
Nurses also need to examine their personal attitudes toward nursing
home residents’ desire for intimacy and sexual expression. If nurses feel
uncomfortable with such expression or feel that it is inappropriate, they
need to consider the reasons for their feelings. If a particular situation
makes a nurse feel uncomfortable, he or she should request the involvement
of another staff member or ask to be reassigned. By providing staff
education related to this topic, facilities can assist nurses in exploring their
personal attitudes, develop strategies to manage residents’ desires for sexual
expression, and reinforce facility policy regarding this issue.
PRACTICE REALITIES
Mrs. Jessup is a 75-year-old nursing home resident with Alzheimer’s
disease. Her husband visits frequently and seems caring. The nursing
assistants report that on several occasions they have walked into Mrs.
Jessup’s room and witnessed her husband holding Mrs. Jessup’s hand at his
genital area. At times, they have found him with his hand beneath her
blanket, touching his wife in her genital region.
In addition to his behaviors with his wife, Mr. Jessup has developed a
friendship with another resident who is mentally competent. The staff has
noticed that when Mr. Jessup visits, this resident usually closes the door.
Once, a nurse entered without knocking and found the pair together in bed.
How should the staff best handle this situation?

1. What attitudes and actions of health care providers can have a negative
effect on the sexuality of older adults? What can have a positive
effect?
2. List the age-related changes that occur for men and women in the
following sexual phases: excitement, plateau, orgasm, and resolution.
3. List at least six factors that can interfere with sexual function in late
life.
Chapter Summary
Nurses need to appreciate that sexual interest and activity can continue into
late life. Ignoring this reality not only limits the ways in which nurses can
aid older adults in achieving a high quality of life but can also cause health
problems that are produced by or manifested through effects on sexual
activity to be overlooked.
Menopause is the permanent cessation of menses for at least 1 year and
occurs for most women around the fifth decade of life. HRT may be
prescribed but needs to be individualized based on the woman’s unique
health profile and risks. Andropause is a decline in testosterone level that
can begin around age 30 or later; it is a slow process and does not occur in
all men. Androgen replacement therapy can be used to treat erectile
dysfunction and other problems caused by low testosterone levels.
The ability to engage in sexual activity is not lost with age, although
factors such as health conditions and the lack of a partner can affect this. An
assessment of sexual function should be part of the evaluation of older
adults. In addition to being caused by reduced hormone levels, sexual
problems can result from medications, genital infections, an unwilling or
unable partner, and cardiovascular disease, diabetes mellitus, pulmonary
disease, obesity, depression, or other health conditions. Older adults with
sexual function problems should be assisted in finding a correction to the
underlying problem, if possible. Nurses must recognize, respect, and
encourage sexuality in older adults. As role models, nurses can foster
positive attitudes. Improved understanding, increased sensitivity, and
humane attitudes can help the older population realize the full potential of
sexuality in their later years.
Online Resources
American Association of Sex Educators, Counselors, and Therapists
http://www.aasect.org
National Institutes of Health Menopausal Hormone Therapy
Information
http://www.nih.gov/PHTindex.htm
North American Menopause Society
http://www.menopause.org
Sexuality Information and Education Council of the United States
http://www.siecus.org
SAGE (Services and Advocacy for Gay, Lesbian, Bisexual, Transgender
Elders)
http://www.sageusa.org
References
Amiri, M., Tehrani, F. R., Rahmati, M., Soudmand, A., Behboudi-Gandevani, S., Sabet, Z., & Azizi,
F. (2019). Low serum testosterone levels and the incidence of chronic kidney disease among
male adults: A prospective population-based study. Andrology, 8 (3), 575–582. doi:
10.1111/andr.12728.
Centers for Disease Control and Prevention. (2019). HIV and older Americans. Retrieved February
16, 2020 from https://www.cdc.gov/hiv/group/age/olderamericans/index.html
Cobin, R. H., & Goodman, N. F. (2017). American Association of Clinical Endocrinologists and
American College of Endocrinology position statement on menopause-2017 update. American
Association of Clinical Endocrinologists, 23 (7), 869–880.
Franco, O. H., Chowdhury, R., Troup, J., Voortman, T., Kunutsor, S., Kavousi, M., … Muka, T.
(2016). Use of plant-based therapies and menopausal symptoms: A systematic review and meta-
analysis. Journal of the American Medical Association, 315 (23), 2554–2563.
Goldstein, I., Goren, A., Li, V. W., Tang, W. Y., & Hassan, T. A. (2020). Epidemiology update of
erectile dysfunction in eight countries with high burden. Sexual Medicine Reviews, 8 (1), 48–58.
Johnson, A., Roberts, L., & Elkins, G. (2019). Complementary and alternative medicine for
menopause. Journal of Evidence-Based Integrative Medicine, 24 , 2515690X19829380. doi:
10.1177/2515690X19829380.
Kinsey, A. (1948). Sexual behavior in the human male. Philadelphia, PA: Saunders.
Kirby, M., Hackett, G., & Ramachandran, S. (2019). Testosterone and the heart. European
Cardiology, 14 (2), 103–110.
Masters, W., & Johnson, V. (1966). Human sexual response. Boston, MA: Little Brown.
Masters, W., & Johnson, V. (1981). Sex and the aging process. Journal of the American Geriatrics
Society, 9 , 385.
Mitchell, C. M., & Waetjen, L. E. (2018). Genitourinary changes with aging. Obstetrics and
Gynecology Clinics of North America, 45 (4), 737–750.
North American Menopause Society. (2017). The 2017 hormone therapy position statement of the
North American Menopause Society. Menopause, 24 (7), 728–753.
Zeller, T., Appelbaum, S., Kuulasmaa, K., et al. (2019). Predictive value of low testosterone
concentrations regarding coronary heart disease and mortality in men and women- evidence
from the FINRISK97 study. Journal of Internal Medicine, 286 (3), 317–325.
CHAPTER 32
CHAPTER OUTLINE
Living With Disability
Principles of Rehabilitative Nursing
Functional Assessment
Interventions to Facilitate and Improve Functioning
Assisting with Mobility Aids and Assistive Technology
LEARNING OBJECTIVES
1. Discuss the challenges for older adults living with a disability.

2. Describe the principles of rehabilitative and restorative nursing.
3. List components of the assessment of activities of daily living and
instrumental activities of daily living for older adults.
4. Identify positions for proper body alignment.
5. Describe types of range of motion exercises.
6. List considerations in older adults’ proper use of mobility aids.
7. Describe measures to promote mental function in older adults.
8. Identify resources to assist in older patients’ rehabilitation.
TERMS TO KNOW
Activities of daily living (ADLs)toileting, feeding, dressing, grooming,
bathing, and ambulating
Assistive technologytechnological tools that enable a person to maximize
independence
Disabilityinability to perform activities normally
Frailtycondition in which a person has poor endurance and wweakness
Handicaplimitation to fulfill functions or a role due to physical, mental,
or social impairment
Impairmentabnormality in organ structure or function that causes a
physical or psychological restriction
Instrumental activities of daily living (IADLs)tasks required for
community living, such as shopping, meal preparation, laundry,
housekeeping, use of telephone, money management, and medication
management
Rehabilitative caretherapies developed by physicians and therapists
focused on returning individuals to their previous level of function
Restorative carecare that assists people in maintaining or improving
current level of function, avoiding decline and complications, and
achieving highest possible quality of life
Sarcopeniaage-related loss of muscle mass
The prevalence of chronic conditions, frailty , and disability among older

adults is significant. In addition, the effects of aging often result in declines
in functional ability. Many older persons must learn to live with limited
mobility, pain, impaired communication, and multiple risks to their safety
and well-being. As increasing numbers of people achieve advanced years,
surviving once-fatal conditions but with residual disabilities, the prevalence
of disability among older adults will rise. The emphasis on saving lives
must be balanced with an emphasis on preserving the quality of the lives
that have been saved. The advantages of modern technology in diagnosing
and treating disease and improving life expectancy may be minimized if
older adults must live with disabilities that result in discomfort,
dependency, and distress.
POINT TO PONDER
Advances in health care technology have enabled people to be saved
from serious illnesses, although in some cases they are left with
significantly limited function and discomfort. Would you want every
effort made to save your life regardless of the consequences? Why or
why not?
REHABILITATIVE AND
RESTORATIVE CARE
Rehabilitative care involves therapies developed by physicians and
therapists focused on returning individuals to their previous level of
function. Usually the need for rehabilitative services arises after a problem
has occurred that affected function, such as a stroke, fracture, or prolonged
state of immobility. Skilled rehabilitative care involves services offered by
physical, occupational, and speech therapists and is eligible for Medicare
reimbursement. Nurses assist in supporting the rehabilitation plan.
Many of the effects of aging and disabilities cannot be eliminated or
significantly improved. Damaged lungs, amputations, diseased heart
muscle, partial blindness, presbycusis, and deformed joints may accompany
patients for the remainder of their lives. Often, these chronic disabilities
receive the least intervention; reimbursement and aggressive attention are
given to restore the function of someone who has suffered a stroke or
fracture, but those who have reached their maximum functional ability from
rehabilitative therapies or who have “no rehabilitation potential” may be
overlooked in their need to maintain function and prevent further decline.
For these individuals, restorative care is beneficial.
Restorative care is primarily offered by nursing staff and does not
require a medical order. It can occur in any setting and includes efforts to
help individuals:
Maintain their current level of function
Improve their functional ability
Prevent decline and complications
Promote the highest possible quality of life
Restorative care enables people to better cope, be maximally

independent, have a sense of well-being, and enjoy a satisfying life. Based
on its aims, restorative care can be appropriate for every older adult.
Frailty is a particular challenge to older persons that must be considered
in rehabilitative and restorative care. Although definitions of frailty can
vary, the term usually describes a clinical state of increased vulnerability in
which a person has poor endurance, fatigue, low activity level, heightened
risk for adverse outcomes, and slower recovery from infection, injury,
psychosocial stresses, and other stressors (Martin & Halloran, 2020).
Some of the frailty is the result of sarcopenia —age-related changes to
the skeletal muscle tissues that cause an accelerated loss of muscle mass.
The major causes of sarcopenia include inactivity, malnutrition, a reduction
in nerve cells, malignancies, and a reduction in anabolic hormones (Cruz-
Jentoft & Sayer, 2019). There is a vicious cycle in that conditions that
contribute to frailty can foster the development of sarcopenia, and in turn,
sarcopenia can lead to the development of conditions that further threaten
function and quality of life.
Older adults who are frail are at high risk for falls, disability,
hospitalization, nursing home admission, and death. Positive health
practices and effective management of health conditions, however, are
beneficial in helping older adults to avoid becoming frail. Early recognition
and intervention for symptoms of frailty (e.g., correcting weight loss and
assisting with muscle-strengthening exercises) can prevent or delay some of
the frailty older adults experience. For this reason, it is especially useful to
review symptoms of frailty during nursing assessments of older adults.
Although disability differs from frailty, handicap , and impairment
(Table 32-1), the term disability will be used throughout this chapter to
discuss rehabilitative and restorative needs.
TABLE 32-1 Terminology Used to Describe Functional Status

aAlthough often used interchangeably, these terms each describe a different status.
LIVING WITH DISABILITY

An accident or a stroke may bring sudden disability to a previously
independent, functional adult, or perhaps a chronic condition progressively
worsens and its disabling impact is more acutely realized. Whatever the
circumstances, few of us are prepared to deal with disability. It is difficult to
accept in ourselves and our loved ones. Relationships, roles, and
responsibilities are disrupted; disfigurement and dysfunction alter body
image and self-concept. Losses and limitations cause a new vulnerability to
emerge and make death seem more real and close. Concern arises over
potential physical and emotional pain, and frustration occurs in wanting to
eliminate the cause of the problem and knowing we cannot. Disability can
be an extremely difficult and devastating mountain to climb.
POINT TO PONDER
What examples have you seen within your own family of differences in
the way people respond to health challenges?

The severity of the disability can be less important to rehabilitation efforts
than the attitude and coping capacity of disabled patients and their families.
People with a mild cardiac problem may confine themselves to their homes,
become preoccupied with their illness, and become unnecessarily
dependent, whereas patients with hemiplegia could return to independent
living in modified apartments, find jobs, and cultivate new friends and
interests. Previous attitudes, personality, and lifestyle have a strong
influence on reactions to disability. A person who has always felt that life
has dealt his or her a bad hand could view a disability as the last straw and
give up all hope. An optimistic person who has approached problems as
new challenges to overcome, however, may be determined not to allow a
disability to control his or her life. Individuals who relish independence and
refuse to let illness slow their lifestyles will respond to disability differently
from those who use real or exaggerated ills for other gains.
The family’s response to the disabled person will also influence that
person’s reactions. Families that reinforce sick role behaviors and insist on
doing everything for the disabled person can cripple him physically and
psychologically, whereas families that promote self-care and treat the
disabled person as a responsible family member can help him to feel like a
normal, useful human being.
KEY CONCEPT
Previous attitudes, personality, experiences, and lifestyle influence
reactions to a disability.

Many losses may accompany disability, such as the loss of function, role,
income, status, independence, or perhaps a body part. Disabled persons
mourn these losses, often demonstrating the same reactions experienced
during the stages of dying. They may deny their disabilities by making
unrealistic plans and not complying with their care plans. They may have
angry outbursts and become impatient with those who are trying to help
them. They may shop for medical advice that will offer them a more
optimistic outlook or invest their hopes in any faith healer they can find. On
one day they may optimistically state that their disability has given them a
new perspective on life, yet the very next day they tearfully question what
they have to live for. These reactions can fluctuate; it is the rare individual
who accepts a disability without some periods of regret or resentment.
KEY CONCEPT
Disability can be accompanied by many losses, including function, role,
income, status, independence, and anatomic structure.
PRINCIPLES OF REHABILITATIVE
NURSING
The principles guiding gerontological nursing care are of particular
significance in rehabilitative and restorative care and include the following
actions:
increase self-care capacity

eliminate or minimize self-care limitations
act for or do for when the person is unable to take action for himself or
herself
KEY CONCEPT
Improving the functional capacity of older adults can promote a sense of
well-being and a higher quality of life.
Efforts to increase self-care capacity could include building the

patient’s arm muscles to enable better transfer to and propelling of a
wheelchair or teaching the patient how to inject insulin with the use of only
one hand. Relieving pain and having a ramp installed for easier wheelchair
mobility are efforts that minimize or eliminate limitations. Obtaining a new
prescription from the pharmacy and assisting with range of motion
exercises are ways in which nurses act for or do for the patient. Whenever
nurses act or do for patients, they need to question what could be done to
enable patients to perform the action independently. Patients may always be
dependent on others for some activities, but for other actions patients can
assume responsibility with sufficient education, time allocation,
encouragement, and assistive devices.
The following guidelines should be remembered in rehabilitative and
restorative nursing:
Know the unique capacities and limitations of the individual. Assess

the patient’s self-care capacity, mental status, level of motivation, and
family support.
Emphasize function rather than dysfunction and capabilities rather
than disabilities.
Provide time and flexibility. At times, institutional routines (e.g.,
having all baths completed by 9 am, collecting all food trays 45
minutes after delivery) cause caregivers to do tasks for patients so that
they may be completed efficiently. Staff desires for efficiency and
orderliness should never supersede the patient’s need for
independence.
Recognize and praise accomplishments. Seemingly minor acts, such as
combing hair or wheeling themselves to the hallway, can be the result
of tremendous effort and determination on the part of disabled persons.
Do not equate physical disability with mental disability. Treat disabled
persons as mature, intelligent adults.
Prevent complications. Recognize potential risks (e.g., skin
breakdown, social isolation, and depression) and actively prevent
them.
Demonstrate hope, optimism, and a sense of humor. It is difficult for
disabled persons to feel positive about rehabilitation if their caregivers
appear discouraged or disinterested.
Keep in mind that rehabilitation is a highly individualized process,
requiring a multidisciplinary team effort for optimal results.
FUNCTIONAL ASSESSMENT
When a person suffers from a disability, functional status, rather than
diagnosis, directs rehabilitative care. Among older individuals, functional
status varies widely. Some older adults actively hold down jobs and
regularly provide volunteer service, others are able to perform activities of
daily living (ADLs) if some assistance is provided, and a portion of them
are so severely impaired that total care is required. Furthermore, functional
status can change within an individual from time to time, depending on the
factors such as control of symptoms, progression of the disease, and mood.
Assessment of functional status involves determining an individual’s
level of independence in performing ADLs and instrumental activities of
daily living (IADLs) . This information is essential for understanding the
rehabilitation needs of the patient. An assessment of ADLs explores the
skills the patient possesses to meet basic requirements such as eating,
washing, dressing, toileting, and moving. The nurse can use an assessment
tool such as the Katz Index of Independence in ADLs. Assessment of
IADLs examines the skills beyond the basics that enable the individual to
function independently in the community, such as the ability to prepare
meals, shop, use a telephone, safely use medications, clean, travel in the
community, and manage finances. Persons can be totally independent,
partially independent, or dependent in their ability to perform these
activities (Table 32-2).
TABLE 32-2 Assessing Capacity to Perform Activities of Daily

Living
For total toileting independence, the ability to reach and transfer to the
commode is most important. A client who needs to be encouraged to toilet
exhibits only partial independence.
KEY CONCEPT
Assessing a person’s functional status involves evaluating his or her
ability to perform both ADLs and IADLs.
When a deficit in ADL capacity exists, the underlying cause must be

identified so that appropriate interventions can be planned. For example, a
person who is partially dependent in bathing—that is, he or she needs to
have a basin of water brought to him—will have different nursing
requirements than one who forgets what he or she is doing as he or she
bathes and needs to be reminded of the next action to take.
INTERVENTIONS TO FACILITATE
AND IMPROVE FUNCTIONING
When functional assessment reveals disabilities and impairments, nurses
should identify areas of functioning that could be improved through
interventions. Some examples of these interventions include positioning,
range of motion exercises, use of mobility aids, bowel and bladder training,
and activities to promote mental function.

Correct body alignment facilitates optimal respiration, circulation, and
comfort and prevents complications such as contractures and pressure
ulcers. When patients are unable to position their bodies independently,
nurses must be attentive to keeping their bodies properly aligned. Figure
32-1 demonstrates proper alignment in various positions.
FIGURE 32-1 A. Supine position. B. Prone position.
C.Lateral position. D. Chair position.
KEY CONCEPT
Correct body alignment facilitates the optimal function of major systems,
promotes comfort, and prevents complications.

Exercise is an essential component of the health maintenance and
promotion plan of every adult and is particularly significant for older adults.
Range of motion exercises have many benefits, including the promotion of
joint motion and muscle strength, stimulation of circulation, maintenance of
functional capacity, and prevention of contractures and other complications.
Teaching the older adult how to perform range of motion exercises or
assisting with these exercises is an important component of rehabilitative
nursing.
Exercises can be done in the following degrees:
active—independently by patients
active assistive—with assistance to the patient
passive—with no active involvement of the patient
During the assessment, all joints should be put through a full range of
motion to determine the degree of movement possible actively, with active
assistance, and passively. The most significant concern is the degree to
which range of motion is sufficient to participate in ADLs. Box 32-1 lists
some of the terms used in describing joint motion.
BOX 32-1 Terms Used to Describe Joint Motion

Flexion: bending
Extension: straightening
Hyperextension: extending beyond normal range
Abduction: moving away from body
Adduction: moving toward body
Pronation: rotating down, toward back of body
Supination: rotating up, toward front of body
Internal rotation: turning limb inward, toward center
External rotation: turning limb outward, from center
Inversion: turning joint inward
Eversion: turning joint outward
Circumduction: moving in a circular manner
Patients should be encouraged to put all joints through a full range of

motion at least once daily. Figure 32-2 demonstrates the basic range of
motion exercises that should be incorporated into the older adult’s daily
activities. When nurses need to assist patients with these exercises, they
should remember the following points:
FIGURE 32-2 Range of motion exercises.
First, offer support below and above the joint being exercised.
Next, move the joint slowly and smoothly, exercising it at least three
times.
Third, do not force the joint past the point of resistance or pain.
Finally, document joint mobility.
Table 32-3 offers a tool that can be used to document the patient’s range
of motion.
TABLE 32-3 Tool for Assessing and Documenting Range of

Motion
With any exercise program, caution must be taken to ensure that the
physical activity does not overexert the older patient. Some of the signs that
would warrant stopping an exercise include the development of:
a resting heart rate ≥100 beats/minute

an exercise heart rate ≥35% above the resting heart rate
increase or decrease in systolic blood pressure by 20 mm Hg
angina
dyspnea, pallor, cyanosis
dizziness, poor coordination
diaphoresis
acute confusion, restlessness
Assisting With Mobility Aids and Assistive

Technology
Wheelchairs, canes, and walkers can make the difference between older
persons living full lives or being confined to their immediate environments.
Mobility aids can enable patients to independently fulfill their universal
needs and enhance functional capacity. If misused, however, these aids can
present significant safety risks; thus, nurses must ensure that these pieces of
equipment are used properly.
KEY CONCEPT
Inappropriately used canes, walkers, and wheelchairs can subject the
older adult to falls and other injuries.
The first principle in using mobility aids and assistive technology is to

use them only when necessary. Using a wheelchair because it is quicker or
easier can result in unnecessary dependency and decline of functional
capacity. The true need for the aid must be evaluated. If a mobility aid is
deemed necessary, it must be individually selected according to the
following criteria:
Canes are used to provide a wider base of support and should not be
used for bearing weight.
Walkers offer a broader base of support than canes and can be used for
weight bearing.
Wheelchairs provide mobility for persons unable to ambulate because
of various disabilities, such as paralysis or severe cardiac disease.
These aids are individually fitted based on the patient’s size, need, and
capacities. Patients should be fully instructed in their proper use. Physical
therapists are excellent resources for sizing and instructing patients for
cane, walker, or wheelchair use. Box 32-2 explains some of the
considerations involved in using these aids.
BOX 32-2 Proper Use of Mobility Aids

Canes
Depending on the disability, various canes may be recommended. Canes
should be individually fitted, usually based on the distance from the
greater trochanter to a distance 6 in. from the side of the person’s foot.
The cane is used on the unaffected side of the body and is advanced
when the affected limb advances. For example, if the right leg is
affected, the person holds the cane in his or her left hand and advances it
with the advance of the right leg.
Walkers
A variety of walkers can provide support and stability during
ambulation. Walkers are sized by the measurement from the patient’s
trochanter to the floor.
The person should place his or her hands on the sides of the walker,
with the elbows slightly flexed. During ambulation, the person advances
the walker and then steps forward.
Appropriate use should be followed during transfer activities also.
When lowering to a seat, the person should back the walker to the seat.
When lifting from a seat, the person’s hands should be on the arm of the
chair. The person pushes on the arms of the chair to a standing position;
the person should not use the walker to pull himself or herself to a
standing position.
Wheelchairs
A wheelchair should be individually fitted. The seat should be slightly
larger than the person’s width to prevent pressure and friction. The
person’s arm should be able to reach the wheels easily, and footrests
should be adjusted to support the patient’s foot in a flat position.
Removable or fold-down armrests facilitate transfer.
Wheelchairs should be checked routinely for ease of wheeling;
function of brakes; and freedom from jagged edges, tears in upholstery,
and broken or missing hardware.
In addition to aids that can help individuals with independent

ambulation, a growing amount of assistive technologies can promote other
aspects of independent function. These can include splints, utensil grips,
Velcro attachments, computers, voice synthesizers, Braille readers, remote
control devices, and robotic arms. Research and testing is being conducted
on the expanded use of artificial intelligence, robots, and other technologies
to compensate for physical and mental limitations. These devices not only
will enable older adults to care for themselves and function within the
community but also afford them the opportunity to remain in the workforce
despite having a disability. Nurses need to keep abreast of technological
advances to be able to understand and utilize them in enhancing
independent function.
Bowel and bladder elimination are important ADLs. Incontinence can have
a profound impact on a person’s general health and well-being. Skin
breakdown can result from the moisture and irritation to which the skin is
subjected. Urine or feces on the floor can cause falls. Soiled, odorous
clothing can lead to embarrassment and social isolation. Infections,
fractures, depression, altered self-concept, anorexia, and other problems can
stem from poor bladder and bowel control.
Educating older adults with incontinence about bowel and bladder
training can help them improve continence. However, the nurse must
evaluate the physical and mental capacity of the patient to achieve
continence before a training program is begun. Some patients may not have
the functional capacity to control their elimination despite good intentions;
to initiate a training program with them would be unrealistic and frustrating.
If the patient has the capacity to be continent, training should begin as early
as possible. Nursing Care Plans 20-2 and 21-1 provide information about
bowel and bladder training programs. Consistency is a crucial factor in
training programs; the gains of the day shift in keeping the patient continent
are lost if the evening and night shifts do not toilet the patient at the
appropriate intervals. Success should be recognized and praised; patients
should not be chastised for accidents, but the reasons for the incontinent
episodes should be discussed with them. Encouraging patients to wear street
clothes promotes a positive self-image and normality and often discourages
regression. Accurate documentation can assist in determining the
effectiveness of the plan.
CONSIDER THIS CASE

Mr. Mann is a single 70-year-old who has
severe joint restrictions in his hips and knee due to arthritis. He walks with
a limp and has considerable joint pain. He has not followed through on
referrals for physical therapy and has rejected recommendations for
surgery, despite being informed that it could decrease his pain and improve
his function. Although he has been fitted for a cane, he does not use it.
During his recent visit to his physician, the nurse asks Mr. Mann why
he doesn’t want therapy, surgery, or to use a cane. He responds, “All that
seems like it is for old people. Can you imagine me trying to meet some
young gal in a club if I’m hopping around on a cane?” The nurse begins to
describe the benefits of therapy, surgery, and cane use, but Mr. Mann
interrupts her. “Look…I appreciate you trying to help, but I’m not ready
for that old people stuff,” he says. “I’m just here to get a stronger
prescription for the pain pills I’m taking.”
THINK CRITICALLY
1. What could be some of the factors causing Mr. Mann’s views
and reactions?
2. What additional information would be useful to know about Mr.

Mann to understand his views and assist him in improving his
function and comfort level?
3. What would be some effective actions to assist Mr. Mann?
KEY CONCEPT
Consistency and adherence to the toileting schedule by all caregivers on
all shifts is essential to bladder and bowel retraining programs.

Promoting physical functioning is only one aspect of rehabilitation. Equally
important are efforts to restore, maintain, and promote mental function. In
institutional settings where the contact patients have with staff mainly
revolves around illness-related issues, or in their own homes where they
may be socially isolated, healthy mental stimulation may be sorely lacking.
Like any other function, mental function can deteriorate if not exercised;
thus, all rehabilitative efforts include the promotion of mental activity.
Mental stimulation is a highly individualized process, based on the
unique intellectual and educational level of the patient. Some people enjoy
reading the classics; others are barely interested in reading the local
newspaper. Some people thrive on large social events, whereas others could
spend days alone solving a crossword puzzle. Some people maintain a large
network of contacts through social media, though others are challenged
using the phone. Some people want to make things happen; others derive
pleasure from watching them happen. This diversity, present in all age
groups, reinforces the need to gear mental activities to the unique capacities
and interests of the individual. Patients can take part in a wide range of
intellectual, recreational, and social activities.
KEY CONCEPT
Like younger adults, older individuals show variation in activities that
bring them intellectual stimulation and enjoyment.
Reminiscence
Reminiscence is one mentally stimulating activity that has a therapeutic
aim. Since Butler and Lewis first described reminiscence, or life review
(Butler & Lewis, 1998), studies have supported the value of this process.
For older adults with normal cognitive function, reminiscence is a means of
improving memory, reducing depression (Rubin, Parrish, & Miyawaki,
2019), resolving past conflicts, validating existence, and enhancing quality
of life (Duru & Dutkun, 2018); for persons with dementia, it improves
communication, mood, cognition, and quality of life (Park, Lerr, Yang,
Song, & Hong, 2019).
Nurses can guide patients in reminiscing through individual or group
means (see also discussion of life review in Chapter 4). Often, patients can
supply meaningful themes for reminiscence. For example, a patient may
comment, “Kids today have it a lot easier than I did when I was young,”
which could lead the nurse to explore the patient’s youth and feelings
associated with that period of his or her life. Knowing something of the
patient’s personal history can help nurses find relevant topics for
reminiscence, such as the patient’s immigration to America, development of
a business, or efforts to assist the country during war time. Themes can be
selected for group reminiscing, including playing old records and asking
participants what their lives were like when those records were popular,
showing old photographs and asking participants what memories arise, and
asking them to describe the important pieces of history they have witnessed.
Perhaps the most important skill for nurses to use in reminiscing activities
is listening.
As the patient discusses the topic, questions can be asked and
comments made to encourage greater exploration. If the patient begins to
ramble aimlessly, he or she can be redirected to the topic by comments such
as, “Yes, you’ve mentioned that before … I can tell it was important to you.
Now tell me what happened after that.”
Reality Orientation
Patients with moderate-to-severe memory loss, confusion, or disorientation
require therapeutic efforts to keep them mentally integrated with the world
around them. For these patients, reality orientation is an effective tool. More
than just a simple review of day, date, weather, next meal, and next holiday,
reality orientation is a total approach to keeping the patient oriented.
Clocks, calendars, holiday theme decorations, and reality boards enhance,
but do not substitute for, staff interactions. Consistency is crucial to
promoting orientation; it makes little sense for the day shift to reinforce to
the patient that she is in a nursing home if the evening shift agrees with the
patient’s claim that she is on her grandfather’s farm.
COMMUNICATION TIP
Routine nurse–patient contacts can be used as opportunities to
enhance orientation. For example, when passing medications, the
nurse can state, “Hello, Mr. Richards. I’m Nurse Jones with your
medicine. How are you on this sunny Tuesday? It’s very warm for
March 10th, isn’t it?” This simple exchange adds no more time to the
act of administering the medications but provides helpful orientation.
Misinformation and misperceptions of the patient should be clarified
simply, for instance: “No, your son will not be visiting today. He
comes on Sunday, and today is Wednesday.”
If the nurse observes that visitors or caregivers become impatient with

the patient for confusing facts or not remembering, they should be tactfully
reminded that a better response is to clarify and state the facts; chastising or
becoming frustrated with the patient for not remembering serves no
therapeutic value.

Every community has its unique resources for persons with rehabilitative
needs; such resources provide education, support, and various forms of
assistance to the disabled and their caregivers. Social workers, physical
therapists, occupational therapists, speech and hearing therapists, and
rehabilitation and vocational counselors are among the professionals who
can offer guidance in locating appropriate resources. Local libraries, health
departments, and information and referral services for older people can also
provide valuable assistance.
Strategies Older Adults Use in Their Work to Get

Back to Normal Following Hospitalization
Source: Liebzeit, D., Bratzke, L., & King, B. (2019). Geriatric Nursing,
41(2), 132–138doi: 10.1016/j.gerinurse.2019.08.003.
Approximately 30% to 60% of persons age 65 years and older suffer a
loss of functional status in which they have difficulty ambulating and
completing ADLs. Losing their function can put older adults at higher risk
for rehospitalization, institutionalization, poorer quality of life, and death.
Because as many as half of hospitalized older adults demonstrate a
disability during the first year postdischarge, efforts to regain functional
ability are important to prevent negative outcomes.
Previous research has suggested that older adults are dedicated to
working to restore normal function following hospitalization due to concern
over potential loss of function and the threat of being confined in, or having
to move from, their home. By conducting in-depth individual interviews
with adults age 65 years and older, this study’s researchers attempted to
identify strategies used by older adults to regain normal function after their
hospitalization. Participants described several strategies that they used to
regain normal function after their discharge from the hospital, including
doing exercises (both self-prescribed and those prescribed by physical
therapists and health care providers) and obtaining support and
encouragement from family, friends, neighbors, and health care providers.
Some participants attributed their inability to regain normal function to poor
physical function, weakness, lack of energy, or pain.
This study provides insight into how nurses can help older adults
restore or increase function following hospital discharge. Pointing out signs
of progress in functional ability to patients, supporting efforts to improve
physical and physiologic condition, and praising efforts to increase activity
can aid patients in regaining normal function. Including family members in
discharge planning discussions and advising them of the importance of their
assistance, encouragement, and monitoring can also be beneficial. In
addition, it can be useful to discuss aspects of the home that could be
viewed as perceived threats to maintaining and improving independence
and assist with plans to address them. Recognizing that many factors
influence older adults’ ability to regain normal function following
hospitalization or a serious illness, nurses need to conduct a comprehensive
assessment to identify patients’ unique needs and challenges in restoring
normal function, and collaborate with patients and their families to develop
postdischarge plans to support restoration of normal function.
PRACTICE REALITIES
Sixty-nine-year-old Mr. Barr had a below-the-knee amputation several
weeks ago and this week began receiving instruction in the use of his
prosthesis. He has been making progress but still has difficulty with
transfers. Mr. Barr gives the impression of a tough guy who has it all under
control, but you have observed him at times looking frightened and
depressed when he is unable to navigate smoothly with his new prosthesis.
At the team meeting that Friday, the social worker reports that Mr.
Barr’s insurance will no longer reimburse for inpatient rehabilitation after
Monday. On Saturday afternoon, the physician visits Mr. Barr and asks him
if he wants to go home. Mr. Barr responds that he would, and the doctor
writes the order for discharge that day.
You know that Mr. Barr lives alone in a two-story townhouse.
Arrangements have been made for a physical therapist from a home health
agency to visit him on Monday. You have concerns about Mr. Barr
managing over the weekend.
What could you do to assist Mr. Barr until the home health agency
visits?
1. Discuss the way in which a disability can impact a person’s body,
mind, and spirit.
2. Consider the way in which your average routine would be altered if
you possessed a disability. What resources could you use?
3. Describe the way in which prejudices and misinformed attitudes
regarding disabilities can affect disabled persons.
4. Identify resources to assist persons in your community who have
aphasia, blindness, bilateral amputation, and alcoholism.
Chapter Summary
The prevalence of disability among older adults is increasing as greater
numbers of people survive once-fatal conditions that leave them with
residual disabilities. Some will need rehabilitation, which involves therapies
developed by physicians and therapists focused on returning individuals to
their previous level of function; others will benefit from restorative care,
which focuses on maintaining function and preventing additional decline.
Restorative care falls within the scope of nursing and can be provided in
any setting.
Some of the frailty of older adults is the result of sarcopenia; frailty, in
turn, can contribute to the development of sarcopenia. It is useful to review
symptoms of frailty during nursing assessments of older adults.
Disability can have an impact on every facet of a person’s life. The
severity of the disability can be less important to rehabilitation efforts than
the attitude and coping capacity of disabled patients and their families.
Many losses may accompany disability, such as the loss of function, role,
income, status, independence, or perhaps a body part. Disabled persons
mourn these losses, often demonstrating the same reactions experienced
during the stages of dying. When a person suffers from a disability,
functional status rather than diagnosis directs rehabilitative care; therefore,
it is important that the person’s level of ADL and IADL independence be
assessed. Interventions are based on the impairments present and could
include positioning, range of motion exercises, use of mobility aids, bowel
and bladder training, and activities to promote mental function. Nurses
support the interventions by educating patients, providing assistance with
exercises, providing and guiding patients in therapeutic activities, and
assuring patients properly use equipment.
Online Resources
Amputations
National Amputation Foundation
http://www.nationalamputation.org
Arthritis
Arthritis Foundation
http://www.arthritis.org
General Disability and Rehabilitation
Disabled American Veterans
http://www.dav.org
National Rehabilitation Information Center
http://www.naric.com
http://www.pva.org
Head Injuries
The Brain Injury Association Inc.
http://www.biausa.org
Hearing Impairments
Dogs for Better Lives
http://www.dogsforbetterlives.org
Hearing Loss Association of America
http://www.hearingloss.org
Independent Living Aids
http://www.independentliving.com
National Institute on Deafness and Other Communicative Disorders
http://www.nidcd.nih.gov
National Association of the Deaf
http://www.nad.org
Neurologic Diseases
American Parkinson’s Disease Association
http://www.apdaparkinson.org
Epilepsy Foundation
http://www.epilepsy.com
Myasthenia Gravis Foundation
http://mysathenia.org
National Huntington’s Disease Association
http://www.hdsa.org
National Multiple Sclerosis Society
http://www.nmss.org
National Stroke Association
http://www.stroke.org
Ostomies
United Ostomy Associations of America
http://www.uoa.org
Spinal Cord Disorders
http://www.pva.org
United Spinal Association
http://www.spinalcord.org
Visual Impairments
American Foundation for the Blind
http://www.afb.org
Blinded Veterans Association
http://www.bva.org
Guide Dogs for the Blind
http://www.guidedogs.com
Guiding Eyes for the Blind
http://www.guiding-eyes.org
Leader Dogs for the Blind
http://www.leaderdog.org
National Braille Association
http://www.nationalbraille.org
National Eye Institute
http://www.nei.nih.gov
National Library Service for the Blind and Print Disabled
http://www.loc.gov/nls
References
Butler, R. N., & Lewis, M. I. (1998). Aging and mental health (5th ed.). St. Louis, MO: Mosby.
Cruz-Jentoft, A., & Sayer, A. A. (2019). Sarcopenia. The Lancet, 393 (10191), 2636–2646.
Duru, A. G., & Dutkun, M. (2018). The effect of reminiscence therapy on the adaptation of elderly
women to old age: A randomized clinical trial. Complementary Therapies in Medicine, 41 (12),
124–129.
Martin, F. C., & Halloran, A. M. (2020). Tools for assessing frailty in older people: General concepts.
Advances in Experimental Medicine and Biology, Vol. 1216:9-19, doi:10.1007/978-3-030-
33330-0_2.
Park, K., Lee, S., Yang, J., Song, T., & Hong, G. S. (2019). A systematic review and meta-analysis on
the effect of reminiscence therapy for people with dementia. International Psychogeriatrics, 31
(11), 1581–1597.
Rubin, A., Parrish, D. E., & Miyawaki, C. E. (2019). Benchmarks for evaluating life review and
reminiscence therapy in alleviating depression among older adults. Social Work, 64 (1), 61–72.
CHAPTER 33
Acute Care
CHAPTER OUTLINE
Risks Associated With Hospitalization of Older Adults
Surgical Care
Emergency Care
Infections
Discharge Planning for Older Adults
LEARNING OBJECTIVES
1. List measures to minimize risks faced by acutely ill older adults.

2. Describe risks and precautions for older patients undergoing surgery.
3. Discuss common geriatric emergencies and related nursing actions.
4. Identify measures to reduce the risk of infection in older adults.
5. Discuss the importance of early discharge planning for hospitalized
older adults.
6. Describe factors that influence postdischarge outcomes for older
adults.
TERMS TO KNOW
Iatrogenic complicationscomplications inadvertently caused by
practitioners or by medical treatments or procedures
Nosocomial infectionshospital-acquired infections
Today’s acute care hospitals play a significant role in geriatric care. Older
adults have a higher rate of hospitalization and longer length of hospital
stay as compared with other age groups (Centers for Disease Control and
Prevention, 2018). Furthermore, older people are significant consumers of
outpatient hospital services. Many age-related changes increase the risk of
injuries and infections and can cause complications with the chronic
conditions that are common in older adults. Further, technology has opened
the door for new diagnostic procedures, enabled malfunctioning older
organs to be repaired and replaced, and made new treatment options
available. Acute care settings are definitely in the geriatric care business,
and nurses in these settings must be familiar with the unique care needs of
older adults.
RISKS ASSOCIATED WITH

HOSPITALIZATION OF OLDER
ADULTS
Many older adults who have lived independently in their homes prior to a
hospital admission are not discharged with the same level of function; in
some circumstances, nursing home transfer is needed. The decline in status
can sometimes be attributed to the effects of aging on the older adult’s
ability to withstand the stress of an acute condition; however, during
hospitalization, older individuals are at high risk for nosocomial infections
(hospital-acquired infections) and iatrogenic complications (complications
inadvertently caused by practitioners or by medical treatments or
procedures). Examples of complications include delirium, falls, pressure
injuries, dehydration, incontinence, constipation, and loss of functional
dependence (Table 33-1).
TABLE 33-1 Potential Risks of Older Adults During

Hospitalization
Nurses should anticipate and minimize the common risks faced by
acutely ill older persons in an effort to promote optimal functional
independence. Some useful measures include the following:
Careful assessment to identify problems and risks

Early discharge planning
Encouragement of independence
Close monitoring of medications and assurance that age-adjusted
dosages are used
Reminders and assistance to patient with frequent repositioning,
coughing, deep breathing, toileting
Early identification and correction of complications, recognizing that
atypical signs and symptoms may be present
Avoidance of urinary catheterization if possible
Strict adherence to aseptic techniques and infection control practices
Close monitoring of intake and output, vital signs, mental status, and
skin status
Environmental modifications to accommodate older patients’ needs
(e.g., room temperature of 75°F, noise control, use of nightlights, and
avoidance of glare)
Assistance, as necessary, with activities of daily living
Patient and family education
Reality orientation as necessary
Referral to resources to promote self-care ability and independence
POINT TO PONDER
What do you perceive to be the rewards and challenges of caring for
older adults during an acute hospitalization?
SURGICAL CARE
Because of improved surgical procedures and the increasing number of
persons living to old age, nurses today are caring for many more surgical
patients of advanced age. Also, people are no longer denied the benefit of
surgery based on their age alone. Surgical intervention has provided many
older people not only with more years to their lives but also with more
functional years. Successful surgical management of an older person’s
health problems depends on the nurse’s understanding of the age-related
factors that alter normal surgical procedures.
KEY CONCEPT
Surgical intervention not only can add years to an older adult’s life but
also can improve the quality and functional independence of those added
years.

In general, older adults have a smaller margin of physiologic reserve and
are less able to compensate for and adapt to physiologic changes. Infection,
hemorrhage, anemia, blood pressure changes, and fluid and electrolyte
imbalances are more problematic in older people. Unfortunately, inelasticity
of blood vessels, malnourishment, increased susceptibility to infection, and
reduced cardiac, respiratory, and renal reserves cause complications to
occur more frequently in older persons, especially during emergency or
complicated surgical procedures. By strengthening older adults’ capacities
preoperatively, maintaining these capacities postoperatively, and being alert
to early signs of complications, the nurse can help reduce the risk of
surgical complications (Fig. 33-1). Table 33-2 lists nursing problems that
may be identified in older adults who have undergone surgery.
FIGURE 33-1 The hospitalized older adult requires
nursing interventions to prevent complications and to
promote a return to wellness.
TABLE 33-2 Nursing Problems Related to Surgery

The gerontological nurse must be sensitive to the fears that many older
patients have concerning surgery. Throughout their lifetimes, today’s older
adults may have witnessed severe disability or death in older persons
having surgery, and they may worry about similar outcomes from their
operation. Patients need to understand the increased success of surgical
procedures through the following advances:
Better diagnostic tools facilitating earlier diagnosis and treatment

Improved therapeutic measures, including surgical techniques and
antibiotics
Increased knowledge concerning the unique characteristics of older
adults
In addition to offering reassurance, the nurse teaches patients and their
families what to expect before, during, and after the operative procedure,
including the following information:
Preoperative preparation—scrubs, medications, nothing to eat by

mouth (NPO)
Types of reactions to anesthesia
Length of the surgery and a brief description of it
Routine recovery room procedures
Expected pain and its management
Turning, coughing, and deep breathing exercises
Rationale for and frequency of dressing changes, suctioning, oxygen,
catheters, and other anticipated procedures
The nurse documents any patient education offered in the patient’s

record so that this information is available to other health care providers.
During assessment and preoperative preparation, the nurse identifies
concerns, questions, and fears and makes the physician aware of these
findings.
The nurse also reviews with the physician the medications the patient is
receiving to determine those that must be continued throughout the
hospitalization. The patient’s routine medications may need to be
administered despite NPO restrictions. For instance, sudden interruption of
steroid therapy can cause cardiovascular collapse. The nurse may learn that
the patient has been taking antihypertensive, tranquilizing, or other
medications before hospitalization. Occasionally, patients forget or are
reluctant to tell the physician about these drugs. Because cardiac and
pulmonary functions can be altered by certain drugs, it is important to make
sure this information is communicated to the physician. Likewise, the
physician needs to know about herbal medications that the patient may be
using because some (such as ginseng and ginkgo biloba) can affect clotting.
Nurses should ensure that basic preoperative screening has been
completed, including the following:
Analysis of blood samples: creatinine clearance, glucose, electrolytes,

complete blood counts, total plasma proteins, arterial blood gases,
cardiac enzymes, lymphocyte count, serum albumin, hemoglobin,
hematocrit, total iron-binding capacity, and transferrin
Chest x-ray
Electrocardiogram (ECG)
Pulmonary function testing: for obese individuals and those with a
history of smoking or pulmonary disease
Nutritional assessment: height, weight, midarm circumference, triceps
skin fold, diet history
Mental status
Because of the direct nature of the care they provide, nurses may be the
only health care professionals to recognize certain problems. For example,
they may discover loose teeth, which can become dislodged and aspirated
during the surgical procedure, causing unnecessary complications. Such a
problem should be brought to the physician’s attention to ensure
preoperative dental correction.
If prolonged surgery is anticipated, another precaution during surgery
preparation is to pad the bony prominences of older patients. Because they
will be lying on a hard operating room table, padding will help prevent
pressure injuries or muscle and bone discomfort following surgery.
KEY CONCEPT
Careful positioning of the patient and padding of bony prominences can
reduce some of the postoperative muscle and bone soreness that older
adults may experience with prolonged surgery.
Infection control must be at the forefront of the nurse’s mind during the
entire hospitalization and begins early during the preoperative preparation.
Promoting a good nutritional state and correcting existing infections are
important preoperative considerations. To further reduce the risk of
infection, three preoperative bathings—in the morning and at bedtime on
the day before surgery and on the morning of surgery, using an antiseptic—
are recommended, as is performing preoperative shaving as close to the
time of surgery as possible.
Finally, although it is the physician’s legal responsibility, nurses can
ensure that the patient’s informed consent has been obtained preoperatively
(see Chapter 8 for discussion of informed consent).

Anesthesia use must be considered carefully in older adults. Because
anesthesia produces depression of the already compromised functions of the
cardiovascular and respiratory systems of the older patient, it must be
carefully selected. Close monitoring by the anesthesiologist during surgery
can detect and prevent difficulties in the patient’s vital functions. Prolonged
surgery for the older patient is discouraged. Rough, frequent handling of the
tissue during surgery is usually avoided because this stimulates reflex
activity, increasing the demand for anesthesia. If inhaled agents are used for
anesthesia, the nurse should be aware that the patient may remain
anesthetized for a longer time because of the older body’s slower
elimination of these agents; turning and deep breathing will facilitate faster
elimination of inhaled agents.
Hypothermia is one of the major complications older adults face
intraoperatively and postoperatively. Factors that contribute to this problem
include the lower normal body temperatures of many older persons, the
cool temperature of operating rooms, and the use of medications that slow
metabolism. The cool environment and shivering that may result can
increase cardiac output and ventilation and deprive the heart and brain of
necessary oxygen; however, shivering occurs less frequently in older
individuals. Furthermore, the slowing of metabolism that occurs with
hypothermia delays awakening and the return of reflexes. Close monitoring
of body temperature is essential. Some hypothermia may be preventable
with proper warming measures; research has demonstrated that warming
during the intraoperative and early postoperative periods resulted in higher
core temperatures and a lower incidence of hypothermia (Baradaranfard,
Jabalameli, Ghadami, & Aarabi, 2019; Gabriel et al., 2019).
KEY CONCEPT
Hypothermia is a major intraoperative and postoperative risk to older
patients.
Frequent, close postoperative observation and monitoring are extremely

important. The decreased ability of older people to manage stress reinforces
the need to detect and treat symptoms of shock and hemorrhage promptly.
Although not fully conscious after surgery, the older person may
demonstrate restlessness as the primary symptom of hypoxia. It is important
that this restlessness not be mistaken for pain; administration of a narcotic
could deplete the body’s oxygen supply even more. Prophylactic
administration of oxygen may be a beneficial component of the
postoperative therapy. Blood loss should be accurately measured and, if
excessive, promptly corrected. Frequent checking of urinary output can help
reveal the onset of serious complications. Finally, fluid and electrolyte
imbalances can be avoided and detected through strict recording of intake
and output. Output should include drainage, bleeding, vomitus, and all other
sources of fluid loss.
KEY CONCEPT
Postoperative restlessness could indicate hypoxia, not pain; inappropriate
administration of a narcotic analgesic could further deplete the body’s
oxygen supply.
Because the older patient has a greater risk of developing infections,

strict attention must be paid to caring for wounds and changing dressings. A
good nutritional status is beneficial to tissue healing and should be
encouraged. To conserve the patient’s energy and provide comfort, relief of
pain is essential. Maintaining regular bowel and bladder elimination,
keeping joints mobile, and helping the patient achieve a comfortable
position can aid in pain control. If medications are used for pain relief,
nurses should pay attention to the reduced activity that may result and to the
prevention of the ill effects of such immobilization. The nurse should also
be aware that positioning on the hard operating room table and pulling and
moving of the unconscious patient may cause muscle and bone soreness for
several days postoperatively. Finally, it is vital to observe the patient for
respiratory depression if narcotic analgesics are administered.
Older patients are particularly subject to several postoperative
complications. Respiratory complications include pneumonia, pulmonary
emboli, and atelectasis. With atelectasis, there may be decreased lung
sounds and a low-grade fever, but the chest x-ray may not show the
condition. Atelectasis increases the risk for the development of pneumonia.
If pneumonia develops in an older individual, it is more problematic than it
would be for a younger adult and requires a longer recovery period.
Cardiovascular complications include embolus, thrombus, myocardial
infarction, and arrhythmias. Cerebrovascular accident and coronary
occlusion occur, but they are less common than other complications.
Reduced activity and lowered resistance can cause pressure injuries to
develop easily. Drug-induced renal failure is common; drugs that
commonly cause this complication include cimetidine, digoxin,
aminoglycosides, cephalosporins, ampicillin, and neuromuscular-blocking
agents. Older postoperative patients, particularly those with hip repair, tend
to have a higher incidence of delirium than the general adult population.
Paralytic ileus, accompanied by fever, dehydration, abdominal tenderness,
and distention, is an additional postoperative complication that the aged
may experience. Table 33-3 lists other complications.
TABLE 33-3 Common Complicating Conditions in Older

Surgical Patients
ADH, antidiuretic hormone; CHF, congestive heart failure; CVP, central venous pressure; ECG,
electrocardiogram; GFR, glomerular filtration rate; IV, intravenous; JVD, jugular vein distention;
NPO, nothing by mouth; OR, operating room; PVD, pulmonary vascular disease; RR, recovery
room.
The nurse is in a key position to help the older patient achieve the
maximal benefit from surgery. The most sophisticated surgical procedure in
the world performed by the most skillful surgeon is of little value if poor
rehabilitative care causes disability or death from avoidable complications.
To combine the principles and practices of surgical nursing with the unique
characteristic of the older patient is an immense challenge to the
gerontological nurse. However, to see the increased capacity and more
meaningful life many older adults derive from the benefits of surgery is an
immense satisfaction.
EMERGENCY CARE
Emergencies in older persons are particularly problematic. First, they occur
frequently because of the age-related changes that lower resistance and
make the body more susceptible to injury and illness. Second, they often
present an atypical picture that complicates diagnosis. Third, they can be
more difficult to treat or stabilize because of older persons’ altered response
to treatment. Finally, they carry a greater risk of causing serious
complications and death. By recognizing emergency situations and
intervening promptly, nurses can spare considerable discomfort and
disability to older patients and, in many situations, save their lives.
Regardless of the type of emergency, the following basic goals guide
nursing actions:
Maintain life functions

Prevent and treat shock
Control bleeding
Prevent complications
Keep the patient physically and psychologically comfortable
Observe and record signs, treatments, and responses
Assess for causative factors
Whenever there is a question regarding whether a true emergency exists,

nurses should err on the side of safety. It is far better to obtain an x-ray or
ECG that results in a negative finding than to believe it would be an
unnecessary bother or expense and have the patient suffer from a delayed
diagnosis.
KEY CONCEPT
When an emergency condition is suspected, it is better to err on the safe
side and obtain diagnostic tests rather than risk delaying the diagnosis.
Box 33-1 highlights some of the emergency conditions that may be

encountered with older adults and related nursing measures.
BOX 33-1 Selected Emergencies for Older

Adults
ACUTE CONFUSION/DELIRIUM
Clinical Manifestations
Rapid decline in cognitive function, disturbed intellectual function,
disorientation to time and place, diminished attention span, poorer
memory, labile mood, meaningless chatter, poor judgment, altered level
of consciousness, restlessness, insomnia, personality changes, and
suspiciousness.
Goal
Identify and correct causative factor.
Nursing Actions
Assess for changes in physical health, stresses, lifestyle changes,
medications taken, dietary intake, or other problems.
Obtain blood samples for evaluation.
Monitor vital signs, intake and output, and behaviors.
Support treatment plan, for example, electrolyte replacement,
medication change, and fever control.
Goal
Protect from injury and complications.
Nursing Actions
Supervise activities closely.
Remove hazardous substances, medications, and machinery from
patient’s immediate environment.
Ensure adequate nutritional intake, toileting, and hygiene.
Goal
Reduce confusion.
Nursing Actions
Limit number of different staff who provide care. Offer consistency
of approach.
Maintain stable, calm environment. Avoid bright lights, excessive
noise, and extreme room temperatures.
Offer orienting statements, such as “Mr. Jones, you are in the
hospital. It is Tuesday evening. Your wife is at your side.”
Clarify misconceptions.
Note: A thorough evaluation is crucial when confusion exists. This

problem can result from a wide range of disturbances such as
hypoglycemia, hypercalcemia, malnutrition, infection, trauma, and drug
reactions.
DEHYDRATION
Concentrated urine, decreased or excessive urine output, weight loss,
output exceeds intake, increased pulse rate, increased temperature,
decreased skin turgor, dry-coated tongue, dry skin and mucous
membrane, weakness, lethargy, confusion, nausea, and anorexia; thirst
may or may not be present.
Goal
Restore lost fluids.
Nursing Actions
Obtain blood sample for the analysis of electrolytes.
Force fluids unless contraindicated. Administer intravenous
solutions as ordered.
Monitor and record intake and output, weight, and vital signs.
Goal
Minimize or eliminate causative factors.
Nursing Actions
Assess for possible causes (e.g., insufficient intake, fever, vomiting,
diarrhea, and wound drainage).
Correct underlying cause.
Monitor and encourage good fluid intake.
Note: The reduction in intracellular fluid that occurs with age

contributes to less total body fluids; thus, any fluid loss is more
significant in older adults. Unless there is a medical need for restriction,
fluid intake should range between 2,000 and 3,000 mL daily. Assess for
special factors that can lead to dehydration, such as diminished thirst
sensations, disabilities that restrict independent fluid intake, altered
mental status, and desires to minimize urinary frequency and nocturia.
FALLS
Patient found on floor or reports falling.
Goal
Evaluate and treat injury sustained from fall.
Nursing Actions
Do not move patient until status is evaluated.
Request x-ray if fracture is suspected.
Control bleeding.
Relieve patient’s anxiety.
Assess vital signs, mental status, and functional capacity. Note signs
and symptoms (e.g., incontinence, tremors, and weakness).
Review events preceding fall (e.g., position change, medication
administration, pain, and dizziness).
Observe and monitor patient’s status for the next 24 hours.
Goal
Prevent future falls.
Nursing Actions
Assess and correct factors contributing to falls (e.g., gait
disturbances, poor vision, confusion, improper use of assistive
device, medications, and environmental hazards).
Teach patient how to fall safely (e.g., protect the head and face and
do not move until checked).
Teach patient how to reduce the risk of falls.
Teach patient to wear safe shoes; avoid long robes.
Teach patient to sit on the edge of bed for a few minutes before
rising.
Teach patient to use rails, particularly in tubs and stairways.
Teach patient to walk only in well-lighted areas.
Eliminate clutter and loose rugs from environment.
Note: An older person who falls once is at greater risk of falling

again; thus, active prevention is necessary. Falls are the second leading
cause of accidental death; the morbidity and mortality associated with
falls increase with age.
MYOCARDIAL INFARCTION
Acute confusion/delirium, dyspnea, reduced blood pressure, pale skin,
and weakness; chest pain may or may not be present.
Goal
Aid in prompt diagnosis.
Nursing Actions
Identify signs early. Signs may be missed or attributed to other
problems.
Even with the slightest suspicion that a myocardial infarction exists,
proceed with a diagnostic evaluation.
Obtain an ECG and blood specimen—sedimentation rate will be
elevated.
Monitor vital signs.
Goal
Reduce cardiovascular stress.
Nursing Actions
Support prescribed treatment. Administer antiarrhythmics as
ordered.
Provide oxygen. Monitor blood gases. Observe for signs of carbon
dioxide retention.
Support limbs.
Control stress.
Relieve pain and anxiety.
Goal
Prevent and promptly identify complications.
Nursing Actions
Perform range-of-motion exercises. Ensure frequent change of
position.
Monitor intake and output. Anuria can develop; straining due to
constipation can produce strain on heart.
Evaluate response to medications. Note adverse reactions (e.g.,
bleeding, bradycardia, and hypokalemia).
Observe for signs of congestive heart failure (e.g., dyspnea, cough,
rhonchi, and rales).
Observe for signs of shock (e.g., drop in blood pressure, increased
pulse, cool moist skin, decreased urine output, and restlessness).
INFECTIONS
Infections are common acute conditions that demand prompt attention. A
variety of factors can be responsible for the high risk of infection in older
adults (Box 33-2).
BOX 33-2 Factors Contributing to the High

Risk of Infection in Older Adults
Age-related changes
Altered antigen–antibody response
Decreased respiratory activity
Reduced ability to expel secretions from the lungs
Weaker bladder muscles facilitating urinary retention
Prostatic hypertrophy
Increased alkalinity of vaginal secretions
Increased fragility of the skin and mucous membrane
High prevalence of chronic disease
Immobility
Greater likelihood of malnutrition, urinary catheter use, invasive
procedures, hospitalization, and institutionalization
Not only do infections develop more easily in older people but they also
are more difficult to identify early because of altered symptomatology. That
is, the atypical presentation of symptoms can complicate early identification
and correction. For example, lower body temperature can cause fever to
appear atypically; reduced cough efficiency can prohibit the productive
cough that can give a clue to a respiratory infection; and anorexia, fatigue,
and altered cognition can be ascribed to other health problems or “old age.”
KEY CONCEPT
Gerontological nurses should suspect an infection when there is any
abrupt, unexplained change in physical or mental function in the older
adult.
The most common infection in the older population is urinary tract

infection (UTI). In older adults, signs of UTI could include confusion,
incontinence, vague abdominal pain, anorexia, nausea, and vomiting.
Patients with diabetes may experience a loss of glycemic control. Diagnosis
can be confirmed by laboratory tests.
Bacterial pneumonia is the leading cause of infection-related death in
older adults. As with other infectious processes, symptoms can be atypical
and include confusion, lethargy, and anorexia, in addition to the typical
signs associated with pneumonia in any age group. Serum and blood testing
are done to confirm the diagnosis.
Careful attention must be paid to infection prevention in older adults.
Measures that assist in this effort include the following:
Promoting good hydration and nutritional status

Monitoring vital signs, mental status, and general health status
Maintaining intact skin and mucous membrane
Avoiding immobility
Ensuring pneumococcal and influenza vaccines have been
administered (unless contraindicated)
Maintaining a clean environment
Restricting contact with persons who have infections or suspected
infections
Storing foods properly
Preventing injuries
Adhering to infectioncontrol practices
DISCHARGE PLANNING FOR OLDER
ADULTS
Hospitalized older adults require early and competent discharge planning to
prevent complications, reduce the risk of rehospitalization, and minimize
stress to themselves and their caregivers. Effective discharge planning is
particularly significant in this era of abbreviated hospital stays that cause
patients to leave the hospital in sicker, more debilitated states.
COMMUNICATION TIP
Nurses should ask questions to aid in assessing the factors that can
influence postdischarge outcomes of hospitalized older people, such
as:
Patients’ perceptions of health status and prognosis

Number and complexity of medical conditions
Prior history of self-care practices
Family or social supports and resources
It is important to remember that the stress of the illness,

procedures, and hospitalization can interfere with patients’ recall and
responses. Helping patients to feel comfortable and relaxed, and
providing ample time for questions to be processed and responses to
be formed, will assist with relevant information being communicated.
It may be necessary to plan several sessions with patients to exchange
information and convey the discharge plan.
CONSIDER THIS CASE

Eighty-two-year-old Mrs. H is brought to
the emergency department by her daughter, with whom she lives. Mrs. H
had been ambulatory and able to perform all self-care activities until 6
days ago, when she became increasingly confused and weak; she has also
lost weight and begun to experience urinary incontinence. She is
diagnosed with bacterial pneumonia and is admitted to the hospital.
THINK CRITICALLY
1. What risks does Mrs. H face during her hospitalization?
2. What can be done to minimize these risks?
3. What plans would you make to assist her daughter in caregiving

activities after Mrs. H’s discharge?
Discharge plans must take into account the needs of the family or
significant others who provide support and caregiving assistance (Fig. 33-
2). The plan must be one that works for all parties involved, not just the
patient, to be fully successful. (A more complete discussion of family
caregiving is provided in Chapter 35.)
FIGURE 33-2 In discharge planning for the older adult,
the nurse must also consider the needs of family
members who may provide care at home.
The nurse should assess and anticipate the patient’s postdischarge needs
as early as possible in order to have time before discharge to adequately
educate the patient and caregivers, make referrals, and suggest home
preparation. Some acute care settings use an interdisciplinary geriatric team
that consults with staff and develops discharge plans. A gerontological
nurse specialist in the acute care setting may also perform this activity.
Frailty as a Predictor of Future Falls in

Hospitalized Patients: A Systematic Review and
Meta-Analysis
Source: Lan, X., Li, H., Wang, Z., & Chen, Y. (2020). Geriatric Nursing,
41(2), 69–74. doi: 10.1016/j.gerinurse.2019.01.004.
Frailty is highly prevalent among older hospitalized patients. The
physical weakness and slowness associated with frailty can negatively
impact people’s lives, increase the risk of falls, and lead to serious injuries
and even death. This study aimed to discover the relationship between
frailty and the incidence of falls in hospitalized patients through the review
of previous studies.
The authors found that factors that increased the risk for falls were
similar to those associated with frailty, such as muscle weakness, gait
alterations, polypharmacy, balance deficits, and a history of falls. There was
evidence that frailty was a significant predictor of future falls in
hospitalized patients.
Preventing injuries and complications during patients’ hospitalization
are priority nursing concerns. Regardless of the reason for the
hospitalization, the nurse should identify the presence of frailty, along with
the manner in which frailty is displayed in individual patients (e.g., inability
to independently rise from a chair, unsteadiness during ambulation, etc.).
Nurses should incorporate measures to address the effects of frailty into
care plans and activities. In addition, a comprehensive assessment can help
the nurse identify factors contributing to frailty; it can also aid the nurse
when planning interventions to reverse, improve, or compensate for
patients’ frailty with the aim of preventing falls during hospitalization and
improving the quality of patients’ lives after discharge.
PRACTICE REALITIES
Mrs. Davis, a relatively active 84-year-old, had a total hip replacement. Her
recovery was complicated by a reaction to an analgesic that caused her
dizziness, severe sedation, and vomiting. Her symptoms caused her to be
less active and to stay in bed, sleeping most of the time. Except for her daily
visits to physical therapy, she spent most of her time resting in bed.
Mrs. Davis was discharged to a nursing home for continued
rehabilitation. Within 48 hours, she was readmitted with pneumonia and
stage 3 pressure injuries that the nursing home claimed were present upon
admission, although this was not documented in the hospital record. Her
condition is now more serious than it was at any time during her initial
hospital stay.
What could have been done to prevent Mrs. Davis’ complications and
readmission? What can a nursing home do to facilitate a patient’s transition
to this setting so that hospital readmissions can be avoided?

1. A new gerontological nurse specialist on an inpatient surgical unit has
been given the task of implementing nursing interventions to help
reduce the older person’s risk of complications during hospitalization.
What protocols, staff development activities, and other actions could
this nursing specialist consider?
2. Develop an outline of concepts you would review in teaching
community-based older adults measures to prevent infection.
3. What prejudices or misinformed views could jeopardize the health and
well-being of acutely ill older people?
Chapter Summary
The reality that older adults are significant users of acute care services
requires that nurses in acute settings be knowledgeable of the needs and
risks of this population. There are many risks that are particularly high
among hospitalized older adults including delirium, falls, pressure injuries,
dehydration, incontinence, constipation, and loss of functional dependence.
Nurses should be alert to and take active measures to prevent these risks. In
addition, it is important for nurses to review the patient’s health history to
assure that providers are aware of all conditions the patient has and
medications and supplements the patient uses.
Older adults have a smaller margin of physiologic reserve than younger
patients and are less able to compensate for and adapt to physiologic
changes, thereby increasing the risks for surgical complications.
Preoperative teaching can help patients and their families understand what
to expect before, during, and after the surgery. Hypothermia is one of the
major complications older adults face intraoperatively and postoperatively,
requiring close monitoring of body temperature. Warming measures can be
used to reduce the risk of this complication. Postoperative restlessness can
be a primary symptom of hypoxia. It is important that this restlessness not
be mistaken for pain; administration of a narcotic could deplete the body’s
oxygen supply even more. Prophylactic administration of oxygen may be a
beneficial component of the postoperative therapy. Strict monitoring of
intake and output is useful to identify fluid imbalances. Good nutrition,
proper pain management, infection prevention, and frequent position
changes to prevent pressure injuries, pneumonia, and other complications
are essential nursing actions.
Emergency conditions occur frequently in older adults due to age-
related changes that lower resistance and make the body more susceptible to
injury and illness; they also can be problematic due to atypical presentation
of symptoms and altered response to treatment. When older adults present
with an emergency condition, nurses should ensure that life functions are
maintained, complications are prevented and identified early, and responses
to treatment are closely monitored.
Infections not only develop more easily in older people but are also
more difficult to identify early because of altered symptoms. For example,
signs of UTI could include confusion, incontinence, vague abdominal pain,
anorexia, nausea, and vomiting; pneumonia can present with confusion,
lethargy, and anorexia. Careful attention to prevention of infections is
important.
Nurses should assess and anticipate the patient’s postdischarge needs as
early as possible in order to have time before discharge to adequately
educate the patient and caregivers, make referrals, and suggest home
preparation. The discharge plan should consider the capabilities and needs
of the family or significant others who provide support and caregiving
assistance to ensure that it is practical for all.
References
Baradaranfard, F., Jabalameli, M., Ghadami, A., & Aarabi, A. (2019). Evaluation of warming
effectiveness on physiological indices of patients undergoing laparoscopic cholecystectomy
surgery: A randomized controlled clinical trial. Journal of Perianesthesia Nursing, 34 (5),
1016–1024.
Centers for Disease Control and Prevention. (2018). Persons with hospital stays in the past year, by
selected characteristics: United States, selected years 1997–2017. Retrieved February 5, 2020
from https://www.cdc.gov/nchs/data/hus/2018/039.pdf
Gabriel, P., Hocker, J., Steinfath, M., Kutschick, K. R., Lubinski, J., & Horn, E. P. (2019). Prevention
of inadvertent perioperative hypothermia: Guideline compliance in German hospitals. German
Medical Science, 17 , Doc07.
CHAPTER 34
Long-Term Care
Chapter Outline
Development of Long-Term Institutional Care
Nursing Homes Today
Other Settings for Long-Term Care
Looking Forward: A New Model of Long-Term Care
LEARNING OBJECTIVES
1. Describe the development of long-term institutional care.

2. Discuss the problems resulting from the lack of a unique model for
long-term care.
3. Identify major categories of standards described in nursing home
regulations.
4. List various roles of nurses in long-term care facilities.
5. Describe the hygiene, holism, and healing needs of long-term care
facility residents.
TERMS TO KNOW
Almshousecharitable institution for poor persons
Regulationsminimum standards developed by government agencies that
must be met to comply with the law and qualify for licensure and
reimbursement
Subacute carelevel of care in which continued management of acute
condition along with assistance with basic care is needed and provided
in a long-term care setting
The long-term care facility is becoming a complex and dynamic clinical

setting for nursing practice. Increasingly, such facilities are caring for a
more medically complex population than ever before; many nursing homes
are establishing subacute care units that provide ventilator care,
hyperalimentation, and other services that were once confined to hospital
settings. Consumers are more informed of the standards of good care and
quality living environments, giving them higher expectations of providers
than previously. Also, for many nurses who have become frustrated with the
caregiving limitations of abbreviated hospital stays and fragmented care,
such facilities offer an opportunity to establish long-term relationships and
practice nursing’s healing arts.
Although the number of facilities providing long-term care has declined
since the implementation of tougher standards, the number of residents who
are served in long-term care facilities has grown along with the growth of
the older population. Among the current generation of people entering their
senior years, a majority will need some type of facility-based or community
long-term care during their lives (National Center for Health Statistics,
2019).
DEVELOPMENT OF LONG-TERM
INSTITUTIONAL CARE
The many positive aspects of geriatric nursing in nursing homes are often
overshadowed by an uncomplimentary image of this care setting,
influenced by a history laden with scandals and the media’s readiness to
highlight the abuses and substandard conditions demonstrated by a small
minority. This negative image is compounded by reimbursement policies
that significantly limit the ability to provide high-quality care. Reviewing
the manner in which nursing home care developed helps to clarify some of
the reasons for the current challenges nurses face in working in this setting
and to avoid similar problems in the future.

Institutions to care for persons who were mentally ill, developmentally
disabled, aged, orphaned, poor, or suffering from a contagious disease were
common in most European countries by the end of the 17th century.
Typically, all of these individuals were housed together, often with
criminals. With limited funds and low public interest in these populations,
care was custodial at best.
In the United States, any type of inpatient care, acute or long term, was
scarce until the 19th century because it was expected that respectable
people would be cared for at home by private help or family. Even when the
number of hospitals increased after 1800, these facilities discouraged long-
term stays by poor persons with chronic conditions. Communities
responded by developing almshouses , which became the primary source of
institutional care. With limited resources, care was basic at best.
Residents who were able were expected to work in the institution.
Many recovered residents with no better option in the community remained
in the institution and received room, board, and a very small salary in
exchange for caring for residents, cooking, and cleaning.
The primary concern of the managers was running an efficient
operation; this was done through the establishment of rules and routines that
offered residents minimal autonomy and individuality of care. During this
era, sociologist Erving Goffman offered a profile of these facilities, which
he labeled “total institutions,” when he characterized them as follows
(Goffman, 1961):
All activities conducted in the same manner, in the same place

All individuals treated in the same manner and required to comply
with the same activities and schedules
Strict, inflexible schedule of activities
Numerous and heavily enforced rules
Activities that furthered the aims of the institution more than serving
the needs of its residents
This approach to care cast residents as inmates rather than as unique

individuals in need of assistance and, in combination with the isolation of
residents from mainstream society, led to an erosion of their identities and
development of apathy, inactivity, and maladaptive and stereotypical
behaviors.
KEY CONCEPT
The many rules and routines that were implemented to keep the poorly
funded early institutions operating efficiently resulted in residents
developing abnormal behaviors.

By the early 1900s, public and charitable institutions began to replace
almshouses. Residents lived in institutions dedicated to their specific
population. Funding remained scarce, so care improved little.
It is significant to note that there was no careful assessment of the
special needs of persons requiring long-term institutional care. There was
no strategic planning and no thought given to the differences between
facilities housing frail, dependent individuals for an extended period, and
other types of institutions. There was neither a model of long-term care nor
a set of standards describing the unique care expectations for this special
population. Instead, facilities providing long-term care modeled themselves
after hospitals, prisons, and other institutions of the period. Patterning
themselves after institutions that served very different populations for very
different purposes was like trying to fit a square peg into a round hole; the
absence of a clear model of long-term institutional care laid a weak
foundation that affected the growth of this clinical setting.
KEY CONCEPT
Long-term care facilities were fashioned after prisons, hospitals, and
other institutions rather than on a model based on the unique needs of the
population served.
In 1935, the enactment of Social Security provided a means for many

older people to seek alternatives to the public and charitable institutions. In
response, small facilities began to develop, offering room, board, and some
personal care. Some of these facilities were operated by nurses or persons
who called themselves nurses; thus, the term “nursing home” became
popularized. In 1946, the government contributed to nursing home growth
by granting funds to help construct these facilities through the Hill-Burton
Hospital Survey and Construction Act. As the name implies, the grant’s
original intent was to assist in the construction of hospitals; therefore, the
physical plant standards attached to the funding reflected characteristics
desirable in an acute hospital setting. Indeed, despite the significant
difference between hospitals and nursing homes, there were no separate
standards for nursing homes. Consequently, nursing homes constructed
during this time, and for many years thereafter, were replicas of hospitals.
Nursing homes modeled hospitals not only in their architectural features but
also in their style of operation. Starched white linens and uniforms, rigid
schedules, passive residents, strict visitation policies, and restriction of pets
were among the similarities.
In the 1960s, the growing older population began to exercise its
political power by requesting increased and improved health care services.
The enactment of Medicaid and Medicare not only helped ease the
hospitals’ frustration with the growing numbers of older patients filling
their beds for extended periods but also provided reimbursement for nursing
homes providing this care. As a result, between 1960 and 1970, the number
of nursing homes more than doubled and the number of residents served in
this setting more than tripled. Unfortunately, most nursing home owners
and operators were business-oriented individuals with minimal experience
and understanding of nursing care. Federal standards ( regulations ) were
minimal, and monitoring and enforcement systems were lax.
Because of deplorable nursing home conditions and resulting public
outrage, the Department of Health and Human Services commissioned the
Institute of Medicine (IOM) to study long-term care facilities and
recommend changes. The IOM study reported widespread problems with
the quality of care and recommended strengthening nursing home
regulations (Institute of Medicine, Committee on Implications of For-Profit
Enterprise in Health Care, 1986). In response, highly stringent nursing
home regulations were developed under legislation known as the Omnibus
Budget Reconciliation Act of 1987 (OBRA’87). OBRA required the use of
a standardized assessment tool, called the Minimum Data Set (MDS);
timely development of a written care plan; reduction in the use of restraints
and psychotropic drugs; increase in staffing; protection of residents’ rights;
and training for nursing assistants.
POINT TO PONDER
What perceptions of nursing homes have you heard family, friends, and
other health care professionals express? How has this affected your
thoughts about employment in this setting?

As this history demonstrates, the lack of a vision and a clear model for
long-term care contributed to disorganization and confusion regarding the
purpose, function, and standards for nursing homes. When nursing fails to
exercise leadership, nursing practice will be determined by those outside the
profession. The essence of long-term care is nursing care; therefore, who
better than nurses to define nursing facility care? Unfortunately, nurses took
a reactive, passive role and allowed persons with minimal understanding of
caregiving to dictate nursing practice.
When nurses do not attempt to correct problems in the health care
system, others will, and public perception will be that nurses are part of the
problem. When conditions in long-term care facilities reached scandalous
proportions, it was not the nursing community that was outraged and
demanded change, but the public. Nurses who worked in nursing homes
witnessed and complained of substandard conditions but took no organized
public action to effect change. Nurses who did not work in nursing homes
often were critical of the conditions that caused them to stay away from this
practice setting, yet they did nothing to improve the situation. When they
are not part of the solution, nurses create the perception that they are part of
the problem.
Entrepreneurial thinking can benefit nursing and patients. In the era of
rapid nursing home growth, many entrepreneurs saw the opportunity to reap
considerable financial gains by owning and operating long-term care
facilities; many did become millionaires as a result. These businesspeople
were not necessarily brighter, richer, or harder working than nurses, but
they were more apt to see opportunities and take risks. By not being
entrepreneurs and owning and operating nursing homes themselves, nurses
not only missed the opportunity to benefit financially but also—and more
importantly—were not in positions of power from which they could
influence the quality of care, staffing levels, salaries, and other critical
aspects of nursing home care.
These lessons should have meaning for nurses and students today, as
they observe financial professionals making decisions that determine
clinical practice, work in settings in which staffing and services are below
acceptable standards, and see new services and agencies develop in
response to income potential rather than need.
POINT TO PONDER
What would you do if you worked in a setting in which care was
substandard?
NURSING HOMES TODAY

Conditions in nursing homes, now commonly referred to as long-term care
facilities, have improved, largely due to federal regulations and increased
professional interest in this care setting. Licensed staff must be on duty
around the clock, nursing assistants must complete a certification process,
the use of chemical and physical restraints has declined, and documentation
has improved. However, problems do remain. Issues such as insufficient
and inconsistent staffing and high staff turnover and conditions such as
pressure ulcers, dehydration, and malnutrition continue to plague this care
setting.

Most nursing homes are concerned with complying with regulations.
Regulations describe minimal standards that a nursing home must meet in
order to comply with the law and qualify for reimbursement (Box 34-1). It
must be emphasized that these standards are the minimum ones that must be
fulfilled for facilities to comply with the law and be licensed and certified.
BOX 34-1 Regulations Related to Nursing

Homes
Resident rights
Freedom from abuse, neglect, and exploitation
Admission, transfer, and discharge rights
Resident assessment
Comprehensive person-centered care plans
Quality of life
Quality of care
Nursing services
Food and nutrition services
Physician services
Specialized rehabilitation services
Dental services
Pharmacy services
Laboratory, radiology, and other diagnostic services
Behavioral health services
Infection control
Physical environment
Administration
Quality assurance and performance improvement
Compliance and ethics program
Training requirements
States can add to the basic federal regulations and create higher
standards that facilities are obliged to meet. Also, the Joint Commission
publishes higher standards that facilities can voluntarily choose to follow
(standards are published in accreditation manuals that are available for
purchase). It is crucial for nurses working in this setting to be familiar with
the regulations pertaining to nursing homes in their specific states.

People who seek nursing home care are those who are functionally
dependent on a long-term basis as a result of physical or mental
impairment. It is the level of function, therefore, not the medical diagnosis,
that influences the need for long-term care. Typically, residents of nursing
homes have dependencies in their ability to fulfill activities of daily living;
many are incontinent and cognitively impaired. About 16% of nursing
home residents are adults under age 65 years, with the remainder being
older; approximately 39% of the residents are over age 85 years of age
(National Center for Health Statistics, 2019). At any given time, only 5% of
the older adult population resides in a nursing home—although as
mentioned, a higher percentage will need this form of care at some point in
their lives (National Center for Health Statistics, 2019).
For most of these residents, admission to a nursing home was not the
first or most desirable choice. In many situations, family members tried to
assist in caregiving but found that caregiving needs exceeded the family’s
capacities. By the time the decision to seek nursing home care is made,
many families are physically, emotionally, and financially drained, adding
to whatever guilt, depression, and frustration they feel about the situation.
Often, a crisis triggers the need for placement in a nursing home, placing
families in the position of having to seek and decide on a facility under less
than ideal circumstances. An important function of the gerontological nurse
is to help residents and their families as they face the challenges of selecting
and adjusting to a nursing home (Boxes 34-2 and 34-3).
BOX 34-2 Factors to Consider When Selecting

a Nursing Home
COST
Daily rate
Type of health insurance accepted
Out-of-pocket costs necessary to supplement health insurance
Services covered and excluded in daily rate
Charge for services not covered in daily rate
Policy regarding care of resident when reimbursement limits are
reached
PHILOSOPHY OF CARE
Custodial versus restorative/rehabilitative
Promotion of independence, individuality, and resident choice
Encouragement of residents and families to be active participants in
care
ADMINISTRATION
Organizational structure
Ownership
Accessibility and availability of administrator, director of nursing,
medical director, department heads
Existence of regularly scheduled meetings between administration
and residents and families
SPECIAL SERVICES
Availability of podiatry, speech therapy, occupational therapy,
physical therapy, transportation, beauty/barber shop
Cost for special services
Conditions and arrangements for transfer to hospital
STAFF
Number of caregivers available on typical shift
Ratio of RNs, LPNs, nursing assistants to residents
Number of supervisory staff on duty on typical shift
Frequency and type of in-service education offered to staff
Appearance, image portrayed by staff
Quality of staff–resident interactions
Courtesy, helpfulness of staff
RESIDENTS
Cleanliness, grooming, general appearance
Type of clothing worn (pajamas, street clothes, clean, wrinkled)
Activity level
Ease of interaction with staff and other residents
PHYSICAL FACILITY
Cleanliness, attractiveness, fresh smelling
Ease of use for disabled and frail
Lighting
Noise control
Safe areas for walking
General fire and safety precautions
Proximity of bathrooms, dining rooms, activity rooms, nursing
stations, and exits to residents’ rooms
Home-like appearance of resident living areas
Visibility of residents to staff
Outdoor areas for residents’ use
MEALS
Meal schedule
Type of food served
Attractiveness, temperature of food served
Availability of staff to assist residents at mealtime
Location where residents dine (e.g., bedroom, communal dining
hall)
Availability of dietitian or nutritionist for consultation
Range of special diets
Ability to have meal substitutions, ethnic preferences
Availability of snacks between meals
ACTIVITIES
Posted activity schedule
Range and frequency of activities
Ability of families and visitors to participate in activities with
residents
Existence of resident council
Mechanisms for residents to have input into planning and
evaluation of activities
Opportunity for residents to engage in activities off facility grounds
Range of bedside activities
CARE
Basic daily care provided
Frequency of contact with licensed staff
Management of special problems; incontinence, confusion,
wandering, immobility
Efforts to increase mobility and function
Dignity, privacy, individuality afforded residents
Frequency at which complications develop (e.g., pressure ulcers,
dehydration, infections)
Management of unusual incidents, emergencies
Evaluations by regulatory agencies
FAMILY INVOLVEMENT
Preadmission preparation offered to families
Orientation and ongoing support to families
Frequency of family conferences
Mechanisms for communicating with families, involving families in
care
Visitation policies
SPIRITUAL NEEDS
Religious affiliation of facility, if any
Availability of chapel, synagogue, meditation room
Visitations from clergy
Measures to assist residents in meeting spiritual needs
BOX 34-3 Measures to Help Families With

Nursing Home Admission of a Relative
PRIOR TO ADMISSION
Encourage the family to visit the facility and allocate a block of
uninterrupted time to spend with them. Review basic information
about the facility and its routines without overloading. Introduce the
family to the director of nursing, medical director, administrator,
and other key personnel.
Ask for information about the resident that will enable staff to
understand the resident’s unique history, needs, and preferences.
Demonstrate an interest in the resident as an individual.
Accompany the family to a private area and offer them an
opportunity to express their concerns and feelings. Communicate to
them that it is normal for families to feel guilty, angry, and
depressed at having a loved one enter a long-term care facility;
assure them that these feelings will improve in time. Advise them
that it is not unusual for the resident initially to be angry at them,
beg to go home, or reject them; assure them that as the resident
adjusts to the facility, these reactions usually diminish.
Describe the rights and responsibilities of families within the
facility.
Provide written description of facts communicated verbally.
AT ADMISSION
Attempt to have a staff member who has met the family prior to
admission meet the family and accompany them through the
admission process.
Inform family members of the location of cafeteria, vending
machines, and rest rooms. If possible, order a snack or lunch tray
for family members so that they may share the resident’s first meal
time in the facility.
Arrange for staff who will be caring for the resident to introduce
themselves to the family. It is beneficial for staff to write their
names on a paper that the family can consult for future reference.
Introduce the family to another resident’s family member and
encourage them to develop a “buddy system.” Often families can
provide significant support to each other and make visitations more
pleasurable.
Advise the family of the anticipated sequence of events for the
resident (e.g., the resident will be examined by the physician this
afternoon, attend a group activity this evening, visit physical
therapy tomorrow morning). Inform the family of the dates and
times for care planning conferences and other events in which they
are invited to participate.
Encourage the family to go home at a reasonable time. Reinforce to
them that the admission process is tiring to both them and the
resident and that both could benefit from some rest. Express
understanding that they and the resident may have many
uncomfortable feelings at this time, but that these feelings normally
improve with time.
DURING VISITATIONS
Encourage the family to be actively involved in care planning and
care activities. Instruct family members on care activities that they
can perform, such as feeding, back rubs, range of motion exercises,
and grooming.
Suggest activities that the family can share with the resident during
visits (e.g., card games, bringing in a pet, compiling a photo album,
reading, puzzles, decorating a bulletin board). If possible, take the
resident to an activity room or outdoors for the visit and encourage
the family to take the resident off the premises for short periods.
Encourage touch between the family and the resident.
Offer and respect privacy during visits.
IN GENERAL
Be courteous and patient. Remember that having a relative in a
health care facility is difficult and can cause various reactions that
can be displaced to staff.
Call the family when there is a change in status or an incident
involving the resident.
Listen to and investigate complaints. Encourage families to discuss
problems and concerns with unit-level staff.
Invite the family’s participation in care planning and delivery to the
fullest extent possible.

Arrangements for transfer to a hospital are important special services that
should be discussed when explaining nursing home selection to the older
client. Other factors to review would include information about the type of
health insurance accepted by the nursing home, the nursing home’s daily
rate, and the policy regarding reimbursement limits.
One of the products of increased regulations has been a greater

emphasis on nursing home residents’ rights. By law, nursing home residents
have the right to (Centers for Medicare and Medicaid, 2020):
Be informed in a language they can understand of facility services and
charges, survey reports, telephone number, and address for contacting
the State Ombudsman and survey agency
Complain to staff, persons in the ombudsman program, and state
survey agency
Receive adequate and appropriate care, and be informed of changes in
condition
Review his or her own medical record
Be informed of services and fees prior to admission
Have privacy during care, during communication with visitors, and
regarding medical and financial information
Be treated with dignity and respect
Be free from abuse and neglect
Have or refuse visitors
Leave the facility for visits
Have family and friends involved
Be free from physical or chemical restraints used for discipline or for
staff convenience
Make independent choices about care, health care providers, dress
style, and activities
Nursing home nurses need to assure residents’ rights are respected.

As mentioned earlier, regulatory changes since OBRA’87 placed new
demands on nursing homes for competent resident assessment, care
planning, quality assurance, and protection of residents’ rights. The
increased demands and complexities of nursing homes necessitate that
highly competent nurses be employed in this setting.
Unlicensed nursing personnel currently deliver most care in the nursing
home setting. This imposes greater demands on licensed staff; not only
must nurses oversee the status of residents but they also must monitor the
competency and performance of unlicensed caregivers (Fig. 34-1). Staff
education, role modeling, good supervision, coaching, performance
evaluation, and correction of performance problems are responsibilities of
most long-term care nurses in addition to their major clinical and
administrative duties.
FIGURE 34-1 Nurses work with other members of the
health care team to ensure quality of care for residents in
long-term care facilities.
CONSIDER THIS CASE

Peggy Simmons is an RN who graduated
from an associate degree nursing program 3 years ago. Several months
ago, she accepted a position as an assistant director of nursing at a nursing
home. She enjoys her work and feels that she has gained an understanding
of nursing home care.
Today, Ms. Simmons is invited to a meeting with the director of
nursing and the nursing home administrator. She is informed that the
director of nursing is resigning and asked to assume the position. Ms.
Simmons expresses some doubt about her ability to fill the role, but she is
assured by the director of nursing and the nursing home administrator that
they have been impressed with her work and believe that she is capable of
meeting the demands of the position. Although she isn’t sure about her
readiness to be a director of nursing, she is told that the current director of
nursing will orient her to the role during the next 2 weeks before she
departs; in addition, she is told that she will receive a substantial salary
increase and have a Monday-through-Friday workweek.
THINK CRITICALLY
1. What are some of the realities that Ms. Simmons should
consider before deciding on the promotion?
2. How can Ms. Simmons determine if she is qualified to accept

the position?
3. What are the benefits and risks to Ms. Simmons if she accepts
the position? What are the benefits and risks to the facility if she
accepts the position?
Gerontological nurses have increasing opportunities for role variety in

the nursing facility. They can fill administrative and management roles as
director of nursing, supervisor, unit nurse coordinator, or charge nurse.
They can fill specialized roles, such as staff development director, quality
assurance coordinator, infection control coordinator, geropsychiatric nurse
specialist, or rehabilitative nurse. Of course, nurses can also be direct care
providers to residents. Each of these roles requires competencies beyond
basic nursing, thereby challenging nurses to obtain additional education and
experience to ensure competent fulfillment of these specialized roles.
Nurses influence the quality of care provided to residents in a variety of
ways. Admission assessments and the completion of the MDS assessment
tool are coordinated by a registered nurse, and most of the entries on the
MDS rely on nursing assessment. Problems identified through the MDS
assessment tool direct care planning activity. The written care plan guides
nursing actions; staffs are held accountable by regulatory agencies for
ensuring that care plans are accurate and followed. Nurses ensure that
nursing assistants provide care appropriately and monitor residents to
evaluate the effectiveness of care and to recognize changes in status. Box
34-4 lists some of the major responsibilities of nurses in this setting.
BOX 34-4 Major Responsibilities of

Gerontological Nurses in Long-Term Care
Facilities
Assist residents and their families in the selection of and adjustment
to the facility.
Assess and develop an individualized care plan based on
assessment data.
Monitor residents’ health status.
Recommend and use rehabilitative and restorative care techniques
when possible.
Evaluate the effectiveness and appropriateness of care.
Identify changes in residents’ conditions and take appropriate
action.
Communicate and coordinate care with the interdisciplinary team.
Protect and advocate for residents’ rights.
Promote a high quality of life for residents.
Assure that residents’ preferences and choices are honored.
Know and ensure compliance with regulatory standards.
Evaluate the performance of supervised staff.
Ensure and promote the competency of nursing staff.
KEY CONCEPT
The Minimum Data Set is a standardized assessment tool that must be
completed on admission, whenever there is a change in the resident’s
status, and annually. Resident Assessment Coordinators are nurses who
have been prepared to complete the Minimum Data Set tool. The
American Association of Nurse Assessment Coordination is the leading
organization preparing nurses for this role.
Unlike many other clinical settings, the average nursing home does not
have physicians and other professionals on-site at all times. Although this
places a greater burden on registered nurses for assessment and
management of problems, it does offer the opportunity for nurses to
function independently and use a wide range of knowledge and skills; as an
example, see Box 34-5, which discusses the role of long-term nurses during
the COVID-19 pandemic. Independent nursing practice and the ability to
develop long-term relationships with residents and their families are among
the challenging responsibilities of nursing in this setting.
BOX 34-5 Long-Term Care Nurses’ Role
During the COVID-19 Pandemic
The COVID-19 pandemic demonstrated the complexity of long-term
care nursing and the need for nurses in the nursing home setting to be
highly competent. More than one third of all deaths related to this
infection were among nursing home residents (Chidambaram, 2020). Not
only was this population at high risk due to their advanced age and
underlying medical conditions but the congregate nature of their living
arrangements placed them in very close contact with others, thereby
causing the virus to quickly spread. Potential recurrence of this infection
and the possibility of the introduction of other infections challenged
nurses to quickly implement actions to protect residents and staff. These
measures included:
Restricting visitors
Developing and implementing symptom screening procedures for
employees
Ensuring employees’ strict adherence to sick leave policies
Carefully assessing residents (including those with atypical
symptoms)
Educating personnel about the infection and related precautions
Ensuring the availability of an adequate supply of personal
protective equipment
Maintaining close communication with local and state health
departments
Designated spaces within the facilities allowed nurses to care for

residents with confirmed infections and to observe residents suspected of
being infected. Nurses collaborated with other health professionals in
determining which residents needed to be relocated to these units and the
manner in which staff needed to be reassigned and prepared. In addition,
nurses took important measures to facilitate psychosocial well-being,
including maintaining communication with residents’ families and
establishing alternative methods of visitation. The demands of this type
of situation reinforce that nursing home nurses need to be highly
competent in order to wear many hats; they need to be extremely skilled
clinicians, educators, managers, and counselors.
COMMUNICATION TIP
In addition to completing the assessment tools that are required in
their facilities, long-term care nurses need to obtain information from
residents that will provide insights into what constitutes a meaningful
quality of life for them. This can be obtained by asking questions such
as:
“What was your typical day like when you lived at home?”
“Do you have people in your life with whom you have regular
contact?”
“What types of activities do you enjoy?”
“What was your schedule like at home?”
“What can we do to help you continue your involvement with the
people and activities that you have enjoyed prior to coming
here?”
It may be best to ask these questions and explore the responses

several days after admission, when residents have had the chance to
recover from the initial stress of entering the facility.
OTHER SETTINGS FOR LONG-TERM

CARE

In recent years, there has been a growth in assisted living communities as
an option for individuals who need some assistance with activities of daily
living and medical management, but whose needs are not complex enough
to warrant 24/7 nursing attention. Assisted living facilities do not have the
stringent regulations that nursing homes are required to meet and have
fewer licensed nurses on-site. While the number of nursing home beds has
been declining, the number of assisted living beds has increased, supporting
a trend toward this type of care. At the present time, most assisted living
care is paid for privately.
As has been witnessed in nursing homes, the population in assisted
living communities has been growing more clinically complex and
presenting greater needs for assistance and medical supervision. Although
the physical environment and lifestyle may be more appealing to consumers
than that of nursing homes, it is important that residents’ care needs be
adequately assessed and met; the minimal presence of on-site licensed
nurses in many assisted living communities could cause care needs to be
missed or delayed in being addressed. Gerontological nurses are challenged
to ensure that appropriate standards of care are developed and practiced in
this setting to avoid the scandalous conditions that plagued the early
development of nursing homes and to advocate for payment options for
assisted living for those individuals who lack private funds to afford this
care.
Unfolding Patient Stories: Henry Williams •

Part 2
Recall from Chapter 16 Henry Williams, who
has chronic obstructive pulmonary disease (COPD). He recently received
pulmonary rehabilitation after another hospitalization for an acute
exacerbation of COPD. Following rehab, he moved to an assisted living
apartment with his wife, Ertha, who has problems with memory and
confusion. How can the nurse help Henry and Ertha transition to assisted
living? What health-promoting, self-care behaviors can the nurse
recommend to help the couple maintain an optimal level of independence
and wellness? Describe how a holistic nursing plan of care for Henry’s
COPD can change when he is hospitalized with an acute exacerbation of
COPD. Explain how the nurse can promote effective transitions in care.
Care for Henry and other patients in a realistic virtual environment:

Increasing numbers of older adults with chronic conditions and/or
disabilities are receiving long-term health and social services in their
personal residences. One form of this is home health care services that
typically are provided by Medicare-certified agencies. To qualify for
Medicare reimbursement for home health services, individuals must be
aged 65 years or older, homebound, and in need of a skilled care service
intermittently that they or a significant other or household member cannot
perform. Medicaid has similar criteria, although they vary state to state. The
Visiting Nurses Association, Veterans Administration, and a variety of
private agencies offer home health services.
There also are other services available to assist persons in the
community who have long-term care needs. These include homemaker
services, respite care, home-delivered meals, telephone reassurance, home
monitoring systems, and other services. In addition to agencies that provide
these services, local faith communities often have programs to assist
homebound individuals. Local social service agencies and hospital
discharge planners can be useful resources in locating services in a specific
community.
LOOKING FORWARD: A NEW MODEL

OF LONG-TERM CARE
As this chapter’s discussion about the development of long-term care
reflected, facility-based long-term care emerged without a clearly defined
model. Rather than a tapestry of a wide range of therapeutic interventions
that enable persons relying on others for long-term assistance to achieve
optimum physical, psychosocial, and spiritual health and well-being, long-
term care facilities are more like a patchwork quilt of poorly fitted
fragments of traditional medical care loosely held together by weak threads
of regulations and institutional rules.
Because most resident needs and care activities in long-term care
settings fall within the realm of nursing, nurses are the logical choice of
professionals to define the model of long-term care. Recognizing the
limitations of the medical model in nursing homes, the themes of the new
model could be holism and healing. Figure 34-2 offers a hierarchy of
residents’ needs that can help nurses and nurses-to-be envision this new
model and challenge them to consider a design for long-term care services
that exceeds the minimum requirements. The levels of needs shown include
hygiene, holism, and healing.
FIGURE 34-2 Hierarchy of nursing home residents’
needs.
Hygiene encompasses the most basic needs including physiologic

needs, assurance of safety of the human and physical environment,
treatment of medical conditions, and restoration and/or stabilization of
physical and mental health. Basic survival depends on the fulfillment of
these needs; however, having these needs met does not ensure a satisfying,
high-quality life.
At the holism level, psychological, social, and spiritual aspects are
considered. To attain harmony and balance among mind, body, and spirit,
individuals need to exercise individual rights, assume responsibility for
self-care to the fullest extent possible, prevent avoidable declines and
dysfunction, and experience a dynamic relationship with the community
inside and outside the facility.
The fulfillment of hygiene and holism needs provides the foundation
for healing to occur. Healing does not imply cure but, rather, the
establishment of a meaningful and purposeful life, using illness as an
opportunity for self-discovery, deepening spiritual awareness and growth,
and transcending the physical being.
Woven within this model of holism and healing are the following
assumptions:
Psychological, social, and spiritual well-being are of equal and

sometimes greater importance than physical well-being.
Medical supervision and treatment are only one component of the
overall needs of residents.
Many of the needs resulting from chronic conditions can be effectively
and safely met with the use of alternative and complementary
therapies.
Caregivers’ presence and interactions affect health, healing, and the
quality of nursing facility life.
The physical environment can be used as a therapeutic tool.
The nursing home is an integral and active member of the community
at large.
The culture change movement has been a positive step in the direction
of supporting this new model of long-term care. Key elements of culture
change typically include creating a physical environment that is more
home-like than institutional, providing consistent assignments of staff,
individualizing care to meet the specific needs and desires of residents,
nurturing positive relationships, offering educational opportunities for staff,
and empowering residents and their caregivers. The Eden Alternative was
one of the early culture change programs that cast a vision for a different
quality of life for nursing home residents. Its founder, Dr. Bill Thomas,
planted the seed that nursing homes needed to offer residents a life worth
living. Many nursing homes have adapted Eden principles to provide an
environment that is more home-like, encourage and respect resident
decision-making, and foster higher-quality relationships between residents
and their caregivers.
Shortly after Dr. Thomas’ launch of the Eden Alternative, the Pioneer
Network was formed. This is an organization consisting of individuals from
a wide range of aging services who provide education and advocate for
culture change. The Pioneer Network has been a leader in the culture
change movement, advancing fundamental changes in values and practices
to create an enriched life for nursing homes residents. Their site (see the
“Online Resources” section later in this chapter) offers many fine resources
for providers and consumers.
Continuing his impact in redefining nursing home care, Dr. Bill Thomas
in 2001 conceptualized The Green House Project with the intent of
designing the ideal nursing home from scratch. The model consists of small,
self-contained homes, in which each home with 8 to 10 residents receives
individualized care and enjoys a more home-like setting. Direct care staff
are cross-trained in roles, so that the same direct care worker may fix
breakfast in the home, run a load of laundry through the washer and dryer,
and offer personal care to residents. In addition to enhancing the quality of
life, research has shown that these homes reduce complications and
avoidable hospitalizations.
POINT TO PONDER
If you could design a long-term care facility that promoted holism and
healing, what would it look like?
Depression, Anxiety, and Pain Among Newly

Admitted Nursing Home Residents
Source: Ulbricht, C. M., Hunnicutt, J. N., Hume, A. L., & Lapane, K. L.
(2019). Journal of Nursing Home Research Science , 5 , 40–48.
Depression, anxiety, and pain are common diagnoses found among
nursing home residents. The purpose of this cross-sectional study was to
describe the prevalence of these problems in newly admitted nursing home
residents.
A sampling of newly admitted residents was selected from Medicare
and Medicaid certified nursing homes in the United States. Residents
completed a pain assessment, and information related to their
sociodemographic profile, diagnoses, mood, behavior, pain level, and
functioning was obtained from the Minimum Data Set (the assessment tool
that the Federal government requires for all Medicare and Medicaid
certified nursing homes). The findings revealed that 36% of these residents
had a diagnosis of depression and/or anxiety, and 15% had a combination of
depression, anxiety, and pain. Residents with pain reported more depressive
symptoms than residents without pain; they were given analgesics for their
pain. Regardless of their pain status, these residents were not provided with
psychiatric medication or psychological therapy. This study showed that
although newly admitted residents had their pain addressed, treatment of
their depression and anxiety were suboptimal.
In nursing homes, the presence of pain often is described by residents,
displayed through symptoms, or anticipated due to specific diagnoses.
However, depression and anxiety may be more subtle and easily missed in
newly admitted residents whose normal behaviors and mood are not known
by staff. For example, a new resident may be quiet and inactive due to
depression; however, nursing staff unfamiliar with the resident’s normal
mood may assume that the behaviors are not unusual for the resident and
may therefore not consider these as potential signs of a problem. Admission
to a nursing home is a significant event that could cause depression and
anxiety; nurses have an important role in noting signs and symptoms that
could indicate the presence of these conditions. To aid in revealing these
problems and ensuring residents obtain appropriate treatment, nurses should
ask newly admitted residents if they have any concerns about their
admission and monitor their behavior and mood.
PRACTICE REALITIES
Nurse Rogers had worked at a nonprofit nursing home that had
implemented culture change programming. Residents were able to go to the
dining room whenever they desired and select from a large menu. Generous
staffing patterns allowed for not only high-quality care but also
individualized activities. Residents were assisted in decorating their
bedrooms in a manner that reflected individual preferences, down to the
selection of a color theme.
Due to family relocation, Nurse Rogers had to find new employment.
She accepted a position as a director of nursing at a nursing home in town.
The nursing home was for profit, constructed in the 1960s with little
modification since. Due to very basic staffing levels, care was task oriented,
and residents had to comply with a rigid meal and bathing schedule.
Concerned, Ms. Rogers met with the administrator and reviewed the
benefits of culture change. She proposed staffing and operational changes
that could support this transformation. The administrator was sympathetic
but told Ms. Rogers that there were no funds for these changes. “How come
the last nursing home I worked at could offer these things for residents?”
Ms. Rogers asked.
The administrator responded, “They were a nonprofit facility with
additional funding from a religious organization. We admit only Medicaid
and Medicare residents and have to rely on those funds. The reimbursement
we receive barely covers the basic services we offer.”
Ms. Rogers is concerned about this inequality and feels all residents
should have access to the best care possible.
What would you do if you were Ms. Rogers?

1. Consider the expectations baby boomers will have when they use long-
term care facilities in the future and outline the environmental features,
services, and operations that will accommodate them.
2. Imagine that you are a director of nursing in a long-term care facility
and describe:
3. Activities that could be planned to encourage the local community to
become involved in facility activities
4. Services the facility could offer persons living in the neighboring
community
5. Programs and services that could be provided for families of residents
6. Describe actions nurses can take to improve long-term care facilities.
Chapter Summary
Long-term care developed without a clear vision for the unique purpose,
function, and nursing roles associated with this segment of care. As a result,
less than ideal conditions developed. Although stringent regulations, a
greater understanding of the unique aspects of long-term care, and the
culture change movement have brought about significant improvements, the
model for long-term care continues to be developed.
There is openness to redesigning long-term care. The challenge will be
to offer a high quality of life for older adults who need increasingly
complex long-term care services in environments that are more home-like
than institutional, as well as to assure the provision and coordination of a
comprehensive network of community-based long-term care services.
Nursing services are an essential component of any long-term care model;
thus, nurses should exercise leadership in the redevelopment of this form of
care. Gerontological nurses must reclaim nursing’s healing role and cast a
new vision for long-term care that can enable residents of nursing facilities
to experience the highest possible quality of life and care for the remaining
time in their lives.
Online Resources
American Assisted Living Nurses Association
http://www.alnursing.org
American Association of Directors of Nursing Services
https:www.aadns-ltc.org
American Association of Nurse Assessment Coordination
http://www.aanac.org
http://www.ahcancal.org
Eden Alternative
https://www.edenalt.org
Gerontological Advanced Practice Nurses Association
https://www.gapna.org
Green House Project
https://www.thegreenhouseproject.org
Leading Age
http://www.leadingage.org
National Association of Directors of Nursing Administration in Long-
Term Care (NADONA)
https://www.nadona.org
National Consumer Voice for Quality Long-Term Care
https://www.theconsumervoice.org
Pioneer Network
https://www.pioneernetwork.net
References
Centers for Medicare and Medicaid. (2020). Rights and protections in a nursing home. Medicare.gov.
Retrieved March 25, 2020 from https://www.medicare.gov/what-medicare-covers/what-part-a-
covers/rights-protections-in-a-nursing-home
Chidambaram, P. (2020). State reporting of cases and deaths due to COVID-19 in long-term care
facilities. Kaiser Family Foundation. Retrieved May 19, 2020 from
https://www.kff.org/coronavirus-covid-19/issue-brief/state-reporting-of-cases-and-deaths-due-
to-covid-19-in-long-term-care-facilities/
Goffman, E. (1961). Asylums. Garden City, NY: Anchor Books.
Institute of Medicine, Committee on Implications of For-Profit Enterprise in Health Care. (1986).
Profits and health care: An introduction to the issues. In B. H. Gray (Ed.), For-profit enterprise
in health care (pp. 3–18). Washington, DC: National Academy Press.
National Center for Health Statistics. (2019). Long-term care providers and service users in the
United States, 2015–2016. U.S. Department of Health and Human Services. Retrieved March
20, 2020 from https://www.cdc.gov/nchs/data/series/sr_03/sr03_43-508.pdf
CHAPTER 35
Family Caregiving
Chapter Outline
The Older Adult’s Family
Family Member Roles
Scope of Family Caregiving
Long-Distance Caregiving
Protecting the Health of the Older Adult and Caregiver
Family Dysfunction and Abuse
Rewards of Family Caregiving
LEARNING OBJECTIVES
1. List the various structures and functions of families.

2. Discuss various roles that family members can assume.
3. Describe classic family relationships.
4. Identify risks to caregivers and ways to reduce them.
5. Describe guidance to offer to long-distance caregivers.
6. Identify signs of elder abuse.
7. Discuss interventions to reduce family dysfunction.
TERMS TO KNOW
Caregiver burdenstresses, challenges, and negative consequences
associated with providing assistance to a person in need
Elder abusethe infliction of physical or emotional harm, neglect,
financial exploitation, sexual mistreatment, or abandonment of an older
adult
Sandwich generationmiddle-aged persons who are caring for their own
children and their parents
Skipped-generation householdhousehold in which grandparent is raising
minor grandchild with no parent present
Aging is a family affair. Whether it is the retiree’s concern about living and
supporting his family on a pension, a middle-aged daughter’s decision to
accept her mother into her household, or a sister’s attempt to care for her
dying brother at home, the impact of one individual’s aging process has a
ripple effect on the entire family unit. This impact is also felt when older
members of the family require assistance with daily needs and care.
Families are absorbing more complex responsibilities for caregiving for
longer periods of time than ever before. With growing numbers of people
reaching the old–old years and the trend toward maintaining very ill older
individuals in the community, the burdens faced by family caregivers will
likely continue to grow. The increase of women in the workforce, mobility
of families, and complexity of family structures resulting from divorce and
remarriage complicate family relationships and caregiving. Nurses need to
understand the various family structures, roles, and relationships in order to
work most effectively with older adults and their caregivers.
KEY CONCEPT
Greater numbers of families are providing more complex care for their
older members for longer periods of time than ever before.
THE OLDER ADULT’S FAMILY

Almost every individual is part of a family unit, although that family may
not reflect the stereotypical nuclear family. In fact, one may find among
older adults a diversity of family structures, including:
couples (married, unmarried, heterosexual, and same sex)
couples with children (heterosexual, same sex, married, and
unmarried)
parent and child or children
siblings
groups of unrelated individuals
multigenerations
When interviewing older adults, it is important to explore all persons

who are “significant others” to an individual and fulfill a family role,
regardless of whether they are unrelated or reside in different households.
For example, a widow can have a friend with whom she shares a close
emotional tie or a cousin in a neighboring community who provides
assistance and support. Likewise, a single individual may be part of a
relationship that has as much commitment as a marriage.
KEY CONCEPT
Persons beyond traditional family members can serve significant
caregiver roles.

One can identify family members by looking for those individuals who
fulfill family functions. In aging families, family functions are somewhat
modified to address the special needs of older persons and focus on the
following:
ensuring fulfillment of physical needs

providing emotional support and comfort
maintaining connections with family and community
handling financial affairs
instilling a sense of meaning to life
managing crises
Asking older adults the following questions can also facilitate the
identification of significant persons who perform family functions for them:
Who checks on them regularly?

Who shops with or for them?
Who escorts them to the clinic or physician?
Who assists with or manages their problems?
Who takes care of them when they are ill?
Who helps them make decisions?
Who assists them with banking, paying bills, and managing financial
matters?
Whom do they seek for emotional support?
All persons fulfilling significant family functions should be included in

the development and evaluation of the care plans of older adults.
Family Member Roles

Frequently, family members assume certain roles as a result of their
socialization process and family needs and expectations. Possible roles
Decision-maker: the person who is granted or assumes responsibility

for making important decisions or is called on in times of crisis; may
not be geographically close or involved in daily activities but is
consulted for problem-solving
Caregiver: the person who provides direct services, looks after, or
assists with personal care and home management of another family
member
Deviant: the “problem child” or nonconformist who has strayed from
family norms; may be the family scapegoat or may provide a sense of
purpose for family members who “rescue” or compensate for this
individual
Dependent: an individual who relies on the other members of the
family for economic or caregiving assistance
Victim: a person who forfeits his or her legitimate rights and may be
physically, emotionally, socially, or economically abused by the family
POINT TO PONDER
What are the dynamics within your own extended family? What different
roles and functions do various members fulfill?
The impact of these roles should be explored when assessing the family
unit. Nurses must be sensitive to the fact that certain “negative” roles may
not have the adverse effects on the family unit that would be anticipated;
likewise, “positive” roles may not be welcomed by the family. For example,
the middle-aged son who drifts from town to town, regularly contacting his
older parents for funds to pay off his latest indulgences, may not function as
a responsible, mature adult, but he may bring excitement and a sense of
being needed to his parents’ lives, thereby bringing them some rewards.
However, his financially secure, responsible brother who takes care of his
parents’ affairs may be less popular within the family because of his
dullness and practicality.
KEY CONCEPT
Even seemingly negative roles can be fostered by and meet certain needs
of the family.

The dynamics among family members can have positive or negative effects
on older individuals. In assessing the family unit, it is useful to explore the
following issues:
How family members feel about each other. Do they love but not like,
admire, respect, or enjoy each other? How do they express affection?
The manner of communication. Do they share daily events or have
contact only on holidays? Is their style of interaction parent–child or
adult–adult?
Attitudes, values, and beliefs. Do they feel that the young should take
care of the old or that children owe their parents nothing? What are
their expectations of family members, friends, and society? Does their
faith imply certain responsibilities?
Links with organizations and the community. How involved are they
with persons outside the family unit? Is the family similar to others in
the community?
As discussed in Chapter 1, the majority of older people are not

abandoned by their children; most do enjoy regular contact with them.
Nevertheless, lifestyles, housing, and societal expectations in Western
culture are not conducive to parents and their adult children living together.
Most older people want to live in their own residences, if possible, and the
majority do. The arrangement of generations living under separate roofs but
within a 30-minute trip of each other is often the most satisfactory. It is
understood that parents and children will provide assistance and share a
household if an unusual circumstance arises.
KEY CONCEPT
Most older people and their families prefer to live near but not with each
other.
More than 9 of 10 older people are grandparents. Grandparenting can be

a positive experience for older adults because they obtain enjoyment,
affection, and a sense of purpose from caring for their grandchildren
without the 24-hour stress of child-rearing responsibilities. In some cases,
grandparents do assume parenting responsibilities; in fact, there has been an
increase in what is referred to as skipped-generation households in which
grandparents are raising grandchildren with no parent present.
Grandchildren can provide new interests and meaning to life. In turn,
grandchildren usually receive the benefit of unconditional love and
attention (Fig. 35-1). As grandchildren grow into adulthood, their
involvement with grandparents often lessens, but a strong bond continues to
exist.
FIGURE 35-1 Caring family relationships are beneficial
for both grandparents and grandchildren.
The relationship between siblings is a strong one. The typical pattern is

for siblings to drift apart during young and middle adulthood but then
reestablish strong ties in later life. Siblings can provide socialization,
emotional support, and financial and household assistance. Usually, earlier
conflicts and differences become insignificant as siblings develop mutually
supportive relationships in later life.
Older couples have a low rate of divorce, although it is increasing.
Rocky marriages often stabilize in later life as the couple faces a new
interdependency. Older spouses look to each other for security, support, and
safety in an imperfect world. After years of experiencing and reinforcing
one another’s behaviors, the couple can understand, anticipate, and
complement one another’s actions. Spouses look after the care and welfare
of their mates and derive security in having someone available to care about
them.
Relationships in old age are affected by the forms of relationships
experienced throughout life. Parents who ignored or abused their children
early in life may produce children who want nothing to do with them in
adulthood. Siblings who have unresolved anger over favoritism displayed
by their parents may refuse to assist when the favored child is in need.
Couples who never shared intimacy and friendship may exist in separate
worlds under the same roof. Nurturing relationships during every stage of
life is an investment in having meaningful, supportive relationships in later
life.
KEY CONCEPT
Children who feel their parents were insensitive to their needs
throughout their lives may be reluctant caregivers to these parents in old
age.
SCOPE OF FAMILY CAREGIVING

Most of the home care of older persons is provided by family members, not
formal agencies. Approximately 25% of all U.S. adults are involved in
parent care, approximately half of whom provide care on a regular basis
(Centers for Disease Control and Prevention, 2019). The average age of a
caregiver is 49, but more than one fourth of caregivers of older adults are 65
years of age or older themselves (Administration for Community Living,
2019; Family Caregiver Alliance, 2019). Nearly half of the caregivers for
older adults are wives; the next largest group of caregivers is daughters and
daughters-in-law. Indeed, today the average woman will spend more time
providing care for her parents than for her children; often, these women are
responsible for care of their parents and children concurrently, causing them
to be named the “ sandwich generation .” As many adult children remain
in their parents’ home longer or return to their parents’ home, a “club
sandwich” generation of caregivers is being seen who care for aging
parents, children, and grandchildren or grandparents, parents, and children.
Growing numbers of people employed full time also carry family
caregiving responsibilities.
KEY CONCEPT
Most of the home care of older adults is provided by family members,
not formal agencies.
Families provide many types of assistance to their older members (Box

35-1). Often, the provision of assistance is a subtle, gradual process. For
example, a daughter may begin by telephoning her mother after the mother
has returned from a physician’s visit and inquiring about medication
changes. As time progresses, the daughter may accompany her mother to
the physician’s office, discuss the medications directly with the physician,
and telephone her mother daily to monitor the response to the drugs.
Eventually, the daughter may need to lift her mother in and out of the car,
push her into the physician’s office in a wheelchair, undress her for the
examination, and administer the medications to her on a regular basis.
BOX 35-1 Types of Assistance Families Provide

to Their Older Members
Maintaining and cleaning the home
Managing finances
Shopping
Transporting
Providing opportunities for socialization
Advising
Explaining
Troubleshooting
Reassuring
Accompanying to physician’s office and hospital
Negotiating services
Cooking and providing meals
Reminding to take medications, keep appointments, and take
actions
Monitoring and administering medications
Performing treatments
Supervising
Protecting
Bathing and dressing
Feeding
Toileting
Assisting with decision-making
Maintaining a file of health documents (see Box 35-2)
BOX 35-2 Health Documents Caregivers

Should Maintain in a File
Birth certificate
Social Security and Medicare numbers
Person’s employment history
Insurance policies
Advance directives
Durable power of attorney
Wills
Deeds
Military discharge records
Titles to vehicles owned
Sources of income
Monthly expenses
Bank accounts, safe deposit boxes
Debts (mortgage, credit card, personal)
Recent tax returns
Location of valuables owned
Prepaid funeral arrangements, cemetery plots
POINT TO PONDER
If you suddenly faced the situation of having to provide care to a parent
or older relative, how would your life change, and how would you
manage the added responsibilities?
LONG-DISTANCE CAREGIVING
An individual who assists someone in need of care who lives more than 1
hour away is considered a long-distance caregiver—a role fulfilled by about
15% of all caregivers (Health in Aging, 2019). The assistance offered can
include arranging and coordinating in-home care, managing finances, and
providing respite. Often, long-distance caregivers begin with occasional
visits, telephone calls, and troubleshooting and then progress to daily
telephone calls and regular visits to the person’s home.
As is necessary with direct caregiving by family members, family
members who do not live close to the person need to discuss the person’s
needs and the family member(s) best able to manage them. Even if a family
member resides close to the person, that family member may not be the best
person to manage care. Nurses may need to guide families in their decision-
making about long-distance caregiving responsibilities by helping them to
review the tasks needed by the person and to evaluate which family
member is best able to assist. Nurses can also aid families by linking them
with services in the person’s community, as well as resources to educate
them about the person’s condition and care. Like family caregivers who
provide daily direct care, long-distance caregivers need to realistically
consider the physical, emotional, social, and economic assistance they can
provide and set limits.
Nurses should advise long-distance caregivers about what issues they
should review during telephone calls with their relative that can aid in
identifying needs, risks, and changes in status. These can include questions
as to when groceries were last purchased, what time the person goes to
sleep and awakens, food consumption, status of prescriptions, contact with
others, and new symptoms. Nurses can recommend to long-distance
caregivers that they plan their visits at times when medical appointments
are scheduled so that they can receive direct information about health care
status and care and ask any questions that they may have. It also is
beneficial for nurses to assist long-distance caregivers in finding local
geriatric care managers, who can assess a person’s needs and coordinate
care locally for the family.
KEY CONCEPT
Maintaining a file of information that can be requested by health care
providers and facilities, as well as that will be needed at the time of
death of the relative, is an important task that all caregivers—near and
long-distance—can fulfill (Box 35-2).
It can be challenging for family members to determine the quality of

care being offered to their loved ones from a distance. Arranging for local
friends or neighbors to visit and communicate observations to the family
can be useful. Paying attention to changes in mood and the occurrence of
unusual incidents (e.g., missing valuables, injuries) can give clues to
potential abuse. Unannounced visits by the family also can aid in assessing
the quality of care provided.
There may come a time when the family determines that the person can
no longer remain in his or her home. The decisions that follow can be
extremely difficult for the family and the individual in need of care.
Admission to an assisted living community or nursing home can be costly
and difficult for the person; having the person move into the home of a
family member can require considerable adjustments and costs. If nursing
home or assisted living community care is decided upon, the nurse should
guide the family in how to select a nursing home and options in the desired
community. If relocation of the person to a family member’s home is
determined to be the best course of action, a realistic discussion of issues to
consider and how this could affect all household members can be valuable.
Family caregiving at a distance does not make family members immune
to feelings of guilt, frustration, anxiety, anger, and depression about their
loved one. Encouraging family members to share their feelings and seek
support groups is helpful. These caregivers also need to be reminded about
the importance of taking care of themselves.
PROTECTING THE HEALTH OF THE

OLDER ADULT AND CAREGIVER
A family is a strong chain of human experience that bonds its members
through life’s challenges and joys; however, that chain is only as strong as
its weakest link. Effective gerontological nursing recognizes that the health
of all family members must be maintained and promoted.
Maintaining older persons’ independence facilitates normality in family
relationships. Having to live with or be cared for by family members can
threaten the status and roles of older persons and cause anger, resentment,
and other feelings to develop (see Nursing Problem Highlight 35-1). Sound
health practices to prevent disease and disability are crucial to maintaining
self-care ability and independence. If illness occurs, aggressive attention
should be paid to avoiding complications and restoring the affected person
to a healthy state. Interventions such as environmental modifications,
financial aid, home-delivered meals, assistance with chores, transportation
for the physically disabled, telephone reassurance, or a home companion
can supplement deficits and strengthen the older person’s reserves for
independent living.

DISRUPTION IN FAMILY FUNCTION
Overview
A disruption in family function exists when the family’s normal activities
are changed due to a transition, crisis, or uncertainly of outcome. When
this problem is present, the family may be unable to meet the physical,
emotional, socioeconomic, or spiritual needs of its members, may deal
with stress ineffectively, may communicate ineffectively or
inappropriately, and may refuse to seek or accept help from others. They
may be fearful, guarded, or suspicious when visited or interviewed.
Illness or injury of family member, change in dependency level of
member, change in role or function of family member, addition or loss of
family member, relocation, reduced income, added expenses, social or
sexual deviance by family member, break in religious or cultural practices
by family members.
Goal
The family will demonstrate support and assistance to members in their
fulfillment of physical, emotional, and socioeconomic needs; the family
will seek and accept assistance from external sources as appropriate.
Interventions
Collect a comprehensive family history that includes profile of family
(include significant others who fill family functions as family
members); age, health, and residence of members; roles and
responsibilities of each member; typical patterns of communication,
problem-solving, and crisis management; recent changes in
composition of the family and members’ roles, responsibilities, and
health statuses; new burdens; and the family’s assessment of problem.
Identify factors related to family dysfunction and plan appropriate
interventions such as family therapy, financial aid, family conference,
visiting nurse, or clergy visit.
Facilitate open, honest communication among family members; assist
in planning family conferences, promoting discussion by all
members, developing realistic goals and plans, and allocating
responsibility; provide privacy for family.
When a member is receiving health services, explain care activities
and expected outcomes, prepare for changes, and involve the family
in care to the maximum extent possible.
Provide caregiver education and support; help caregivers identify
community resources; and emphasize the importance of respite for
caregivers.
Make the family aware of support and self-help groups that can assist
them, such as Alzheimer’s Disease and Related Disorders
Association, American Cancer Society, Alcoholics Anonymous, and
American Diabetes Association.
If the caregiver is a spouse or sibling, chances are that he or she is of

advanced age as well. Even the children of the older person can be older
adults themselves. The physical, emotional, and social health of the
caregivers must be evaluated periodically to ensure that they are competent
to provide the required services and are not jeopardizing themselves in the
process. Provisions must be made for what gerontological nurses refer to as
caregivers’ TLC:
T—training in care techniques, safe medication use, recognition of

abnormalities, and available resources
L—leaving the care situation periodically to obtain respite and relaxation
and maintain their normal living needs
C—caring for themselves via adequate sleep, rest, exercise, nutrition,
socialization, solitude, support, financial aid, stress reduction, and health
management
Gerontological nurses should review the TLC needs of caregivers

during every contact to ensure their continued effectiveness.

Family caregivers are often senior citizens themselves. Even if they are
younger children of an older adult, they are often 60 years of age of older.
COMMUNICATION TIP
During contact with family caregivers, the nurse should ask the
caregivers how they are doing. The nurse can preface questions about
their status with statements such as the following:
“Caregiving is quite challenging, and it’s not unusual for

caregivers to feel physically and emotionally exhausted.”
“It is very special of you to care for your mother as you do, but
I’d suspect that it’s not easy on you.”
These statements imply an understanding of the difficulties with

the role and can invite honest expressions of frustrations and needs.
A particularly vulnerable group of caregivers is middle-aged daughters

who are a likely caregiver group. After years of sacrificing and struggling
with child rearing, they are beginning to taste some freedom as their
children gain independence and begin to leave home. They are concerned
for their children’s success and well-being and experience ambivalence over
the less intense parental role. Ever-increasing numbers of them are in the
workforce, perhaps resuming delayed careers. Some may be coping with
spouses who are experiencing midlife crises, having mixed feelings about
their marriage, or reacting to undesirable changes in their physical
appearance. They are clouded with the “superwoman” myth and desperately
try to be the supportive parent, understanding wife, exciting lover,
interesting friend, and aspiring employee. In short, they are overwhelmed.
At this point in life, the final straw may be dependent parents and their
demands. These daughters feel that they certainly cannot deprive their
parents, trust their care to strangers, or institutionalize them. However, what
will this mean to their careers, income, marital relationships, friendships,
leisure pursuits, and energy? As a growing number of middle-aged women
confront this dilemma, special nursing intervention is warranted. Box 35-3
describes some ways in which nurses can aid family caregivers.
BOX 35-3 Nursing Strategies to Assist Family

Caregivers
Guide the family to view the situation realistically. Perhaps a leave
of absence rather than resignation from a job is warranted to assist a
parent or spouse through convalescence. Perhaps the needs are such
that a lay caregiver (e.g., family member) will not be able to care
for them adequately. Often, an objective outsider can guide the
family in viewing the real situation and understanding the extent of
care needs.
Provide information that can assist in anticipating needs.
Caregivers need to be guided in exploring the various scenarios that
can arise and developing plans before a crisis occurs. Encourage the
expression of feelings. Raised with an abundance of “shoulds” and
“oughts” regarding the treatment of older persons, families need to
know that the guilt, anger, resentment, and depression they feel are
neither uncommon nor bad.
Assess and monitor the impact of the caregiving on the total family
unit. Although caregivers may feel that they alone are assuming
responsibility for care, they need to examine the effects on the total
family unit. How will their children’s tuition be paid if they quit
their jobs to care for a parent? Will someone have to forfeit a
bedroom if the relative moves in? What is the relationship of the
spouse with the in-laws? Who will help lift grandma into the tub?
Will the family be able to take vacations and entertain at home? Is
someone available to relieve them if they want to go out for a
special occasion?
Introduce and promote a review of care options. Often family
members believe that care must be one of two extremes:
institutionalization or total care provided solely by the caregiver.
Although these are options, other possibilities exist within these
extremes, including home health aides, live-in companions,
geriatric day care, or shared family care in which the elder lives at
specific times with various relatives, or relatives spend designated
days at the elder’s home. Caregivers also should be aided in
identifying their limitations and the need for institutional care when
necessary. See Chapter 10 for more information about various
services along the continuum of care for the elderly and their
caregivers.
FAMILY DYSFUNCTION AND ABUSE
Many factors can threaten the healthy functioning of the family unit; the
gerontological nurse must be skilled in identifying such problems and
providing interventions for them (see Nursing Problem Highlight 35-1).
Family dysfunction occurs in many forms, ranging from an older parent’s
domination and manipulation of an adult child, to incestuous relationships.
A lifelong history of dysfunction may exist, or the dysfunction may be a
recent problem, associated with a wide range of factors (e.g., divorce, loss
of income, increased dependency of older family member, and illness of
caregiver). Families experiencing dysfunction may be
less able to fulfill the physical, emotional, socioeconomic, and spiritual

needs of their members
rigid in roles, responsibilities, and opinions
unable or unwilling to obtain and use help from others
composed of members with psychopathology or behavioral disorders
inexperienced or ineffective at managing crises
ineffective or inappropriate with their communication and behavior
(including learned violence patterns)
One form of dysfunction that has gained increased visibility in recent

years is elder abuse . One out of every ten individuals over the age of 60
experiences some form of abuse, and this statistic is believed to be lower
than that which actually occurs due to victims being afraid or unable to
report their abuse (United States Department of Justice, 2019). The profile
of the older adult at greatest risk for abuse is a disabled woman, older than
75 years of age, who lives with a relative and is physically, socially, or
financially dependent on others. It is important to remember that abuse
occurs in all sorts of families, regardless of social, financial, or ethnic
background and can present in many forms, including
infliction of pain or injury

withholding of food, money, medications, or care
confinement, physical or chemical (drug) restraint
theft or intentional mismanagement of assets
sexual abuse
verbal or emotional abuse
neglect
abandonment
KEY CONCEPT
Both the actual commission of a harmful act and the threat of
committing it are considered abuse.
The older adult may be reluctant to report or admit to mistreatment.

One reason could be that the older adult is dependent on the family member
who is abusing him or her and therefore feels powerless and helpless to
confront that person. This situation can exist when there is a synergistic
dependency between the older adult and the family caregiver (Bornstein,
2019). For example, the caregiver may be economically dependent on the
older person who, in turn, is dependent on the caregiver, and the caregiver
uses the threat of abandonment to manipulate and financially abuse the
older person. The older person fears losing the source of help on which he
or she depends and therefore allows the situation to continue without
bringing outside attention to it.
Subtle clues of abuse include malnutrition, failure to thrive, injuries,
oversedation, unexplained financial problems, and depression. Nurses can
assess for abuse using a tool such as the Elder Mistreatment Assessment
Instrument developed by Fulmer (2017), which has been used for over two
decades and is currently recommended by the Hartford Institute for
Geriatric Nursing (see the “Online Resources” section later in this chapter).
Nurses must manage potentially abusive situations tactfully. Once abuse is
detected, the nurse needs to assess the degree of immediate danger and take
appropriate actions. Abused persons must be assured that their plight will
not be worsened by making the abuse public; they may prefer being
verbally threatened or having their money taken to the alternative of living
in an institution or foster home. (See Chapter 8 for legal considerations
regarding elder abuse.)
The family needs empathy, not judgment, from the nurse. Although
some individuals are consciously malicious and abusive for their own gain,
most abusers are distressed persons who find themselves in stressful
caregiving situations and are coping ineffectively. Abuse can also be
associated with a family pattern of violence, emotional or cognitive
dysfunction of the abused or the abuser, a history of dependency of the
abuser on the victim, or retaliation for a history of earlier abuse. A good
family history can be helpful in gaining insight into the family dynamics
that could contribute to abuse.
Abuse may be stopped and family health salvaged by helping the family
find effective ways to manage its situation, such as counseling or respite
care. The nurse must consider that caregiver burdens often increase over
time; therefore, ongoing interventions are necessary to prevent future abuse
after the immediate episode has been resolved.
REWARDS OF FAMILY CAREGIVING

A caring, interested family is one of the most valuable resources an
individual can possess in old age. In turn, the love and richness of
experience offered by older persons adds a unique depth and meaning to the
family. Caregiving experiences provide opportunities for relatives to learn
more about each other as individuals and to obtain gratification in the
young giving something back to the aged who may have sacrificed for
them. Gerontological nurses must view older adults in the context of their
family units and structure care to enhance the functional capacity of all
family members.
CONSIDER THIS CASE

Mary K is a 45-year-old single parent who
is the sole wage earner for herself and her three teenage children. Several
years ago, when Ms. K’s father was diagnosed with dementia, she
arranged to have him move into an apartment in the same apartment
complex where she lives. His condition has since deteriorated, and he is
now incontinent and unable to eat or dress without assistance; he has also
started fires in his apartment and has been found wandering around the
complex grounds at all hours of the night. Ms. K has decided to take her
father into her own three-bedroom apartment. Ms. K’s two daughters share
one bedroom, her son has his own room, and she has one bedroom for
herself; therefore, she has moved her father into her son’s room, much to
her son’s resentment. In fact, her son states that he cannot stand the urine
odor and noise made by his grandfather, so he has begun sleeping on the
living room sofa and staying at friends’ homes whenever possible. Ms. K’s
father’s pension is not sufficient to pay the additional cost for a larger
apartment because of the expense of his medication and incontinence care
supplies.
Between the stress and her father’s nighttime activity, Ms. K is unable
to obtain adequate rest and has been late for work and “nodding off” at
work as a result. Her employer knows of her situation but states that Ms.
K’s job could be in jeopardy if she is unable to perform her duties and be
dependable. Although Ms. K’s children understand that their grandfather
has no one else to care for him, they are angry at how this situation has
disrupted their lives: They no longer feel comfortable bringing friends
home, they forfeit social activities to help with their grandfather’s care,
and they have less money to spend. Together, the children confront Ms. K
and suggest that their grandfather be placed in a nursing home. Ms. K
becomes upset and responds, “How can you even suggest putting your
own flesh and blood in a place like that? If it kills me, I’ll never put your
grandfather in a nursing home.”
THINK CRITICALLY
1. Describe the actual and potential problems associated with
caring for Ms. K’s father.
2. Discuss the impact of this situation on each family member.
3. Describe approaches that could be used to introduce Ms. K to

other caregiving options, including nursing home care of her father.
4. Develop a care plan to assist this family.
Experiences of Caregivers by Care Recipient’s

Health Condition: A Study of Caregivers for
Alzheimer’s Disease and Related Dementias
Versus Other Chronic Conditions
Source: Tang, W., Friedman, D. B., Kannaley, K., Davis, R. E., Wilcox, S.,
Levkoff, S. E., …, Belza, B. (2019). Geriatric Nursing , 40 (2), 181–184.
Caregiving places considerable demands on family members and can
impact every aspect of their lives. Although care plans and strategies are
developed to meet the needs of clients, the needs of their caregivers often
are overlooked.
This study examined the experiences of caregivers. The caregivers were
divided into two groups: those who cared for persons with Alzheimer’s
disease and other dementias and those who cared for people with other
chronic conditions. Participants were asked to report on their health status,
the type of assistance they provided, the level of support they perceived
themselves receiving, and their perception of how caregiving interfered
with their lives.
Over half of the 650 self-identified caregivers who responded indicated
that their caregiving activities interfered with their lives to some degree.
There was a relationship between the perceived amount of support the
caregivers felt they received and how they perceived caregiving to interfere
in their lives—that is, the greater the support, the less the caregiving
interfered. There was no significant difference between the caregivers who
cared for people with dementias versus other chronic conditions regarding
the caregivers’ health status, type of assistance they provided, and
perceived support.
Providing support to caregivers is crucial to ensure that the older adults
who receive care have healthy caregivers for as long as possible and to
prevent health problems in caregivers. Because the type of support
caregivers need can vary, nurses need to invest time with caregivers to
assess their needs and assist them in obtaining the support they require. It
can be helpful to identify community resources and services that could ease
their burdens, such as local support groups, providers of home-delivered
meals, and respite services. To ensure that the provided support is what the
caregivers perceive as beneficial, the nurse should regularly evaluate the
caregiving situation with the caregivers.
PRACTICE REALITIES
Seventy-year-old Mr. Warren has recently been discharged from the
hospital with a new colostomy. At the first home visit, the nurse finds Mr.
Warren living alone in an extremely dirty house; roaches and mouse
droppings are evident. The house is cluttered and in desperate need of
repair.
Concerned, the nurse asks Mr. Warren if he has any family or friends
who can assist him. “No,” he responds, “I don’t associate with any of my
neighbors, and I’ve been divorced for over 30 years. I’ve got two kids, but
they are too wrapped up in their own lives to help me.”
When Mr. Warren mentions the names of his son and daughter, the
nurse recognizes them as affluent leaders of the community. She asks Mr.
Warren if she can contact them and he agrees, adding, “It won’t do any
good, though. They are selfish snobs.”
When the nurse phones Mr. Warren’s children, she is surprised by their
reaction. The son says he has no interest in talking with her. The daughter
does speak with the nurse. “My father is not a nice man,” the daughter
contributes. “He was abusive to my mother and did nothing to help us.
There were times we had no food and were evicted because he gambled and
drank his money away. It is hard to describe how cruel he was to us. My
mother left him as soon as we were out of the house. Had she stayed with
him, he probably would’ve killed her. My father never wanted to have
anything to do with us once we were grown. I’m sorry to hear of his
situation, but my brother and I wrote him out of our lives years ago.”
What would you do if you were this nurse?

1. Describe the potential changes the average family would face if they
suddenly had to provide care for an older relative.
2. Discuss satisfactions and benefits family members can derive from
caring for older relatives.
3. Identify resources in your community to assist families with
caregiving.
Chapter Summary
As increasing numbers of people are achieving advanced years, families are
faced with the challenges of caring for their older relatives. This situation
has become more complicated due to a greater number of women in the
workforce, mobility of families, and complexity of family structures
resulting from divorce and remarriage.
There is considerable diversity among families, and persons beyond
traditional family members can play important roles in the lives of older
adults. When assessing family members, nurses need to inquire about those
significant others who provide physical, emotional, social, spiritual, and
financial support.
Often, various family members assume certain roles as a result of their
socialization process and family needs and expectations; these can include
decision-maker, caregiver, deviant, dependent, and victim. Nurses must be
sensitive to the fact that certain “negative” roles may not have the adverse
effects on the family unit that may be anticipated; likewise, “positive” roles
may not be welcomed by the family. Family dynamics are important to
assess because they can have positive or negative effects on the older
person. Learning about family relationships also can provide insights into
responsibilities, satisfactions, and concerns that the older adult may have.
Approximately one in four adults is involved in the care of a parent, and
nearly half of these caregivers are older adults themselves. Caregivers of
older adults may also have responsibilities for children and grandchildren,
creating burdens that can threaten their health. The health and well-being of
caregivers should be regularly assessed. Nurses should discuss with
caregivers the importance of their own self-care and assist them in finding
support and assistance as needed.
Family dysfunction occurs in many forms. It can be a new problem or
one that has been present for a long time. Elder abuse is a form of
dysfunction that has increased in recent years and can exist in many forms.
Subtle clues of abuse include malnutrition, failure to thrive, injuries,
oversedation, and depression. Nurses need to be alert to signs of abuse and
assist the family in finding effective ways to manage their problems.
Although it can be challenging and demanding, serving as a caregiver to
a family member has its satisfactions. By providing education, assistance,
and guidance, the nurse can promote an experience that is beneficial to the
older adult and the caregiver—one that promotes memories of the
experience that highlight the satisfactions rather than the burdens.
Online Resources
Caregiver Action Network
https://caregiveraction.org
Children of Aging Parents
www.caps4caregivers.org
Elder Mistreatment Assessment
https://consultgeri.org/geriatric-topics/elder-mistreatment-and-abuse
Family Caregiver Alliance
www.caregiver.org
Family Caregiving 101
www.familycaregiving101.org
Try This: Best Practices in Nursing Care to Older Adults:
National Alliance for Caregiving
www.caregiving.org
National Center on Elder Abuse
https://ncea.acl.gov
National Council on Family Relations
http://www.ncfr.com
National Eldercare Locator
https://eldercare.acl.gov/Public/Index.aspx
Well Spouse Association
www.wellspouse.org
References
Administration for Community Living. (2019). Family caregivers. Retrieved March 20, 2020 from
https://acl.gov/sites/default/files/programs/2019-
07/Family%20Caregivers%20Examining%20caregiver%20characteristics.pdf
Bornstein, R. F. (2019). Synergistic dependencies in partner and elder abuse. The American
Psychologist , 74 (6), 713–724.
Centers for Disease Control and Prevention. (2019). Caregiving. Retrieved March 3, 2020 from
https://www.cdc.gov/aging/caregiving/
Family Caregiver Alliance. (2019). Caregiver statistics: Demographics. Retrieved March 3, 2020
from https://www.caregiver.org/caregiver-statistics-demographics
Fulmer, T. (2017). Elder mistreatment assessment. ConsultGeri, Issue 15. Hartford Institute for
Geriatric Nursing. Retrieved March 20, 2020 from https://consultgeri.org/try-this/general-
assessment/issue-15
Health in Aging. (2019). Tips for the long-distance caregiver. Retrieved March 5, 2020 from
https://www.healthinaging.org/tools-and-tips/tips-long-distance-caregiver
United States Department of Justice. (2019). Elder abuse statistics. Retrieved March 20, 2020 from
https://www.justice.gov/file/1098056/download
CHAPTER 36
End-of-Life Care
CHAPTER OUTLINE
Definitions of Death
Family Experience With the Dying Process
Supporting the Dying Individual
Stages of the Dying Process and Related Nursing Interventions
Advance Directives
Supporting Family and Friends
Supporting Through the Stages of the Dying Process
Supporting Nursing Staff
LEARNING OBJECTIVES
1. Discuss the difficulty people may experience in facing death.

2. Describe the stages people commonly go through when facing death
and describe related nursing interventions.
3. List physical care needs of dying individuals and related nursing
interventions.
4. Discuss ways in which nurses can support family and friends of dying
individuals.
5. Discuss ways in which nurses can support other nursing staff dealing
with dying patients.
TERMS TO KNOW
Assisted suicidesuicide committed with the help of another individual
Do not resuscitate (DNR)medical order advising providers not to initiate
cardiopulmonary resuscitation in the event of cardiac or respiratory
arrest
End of lifeperiod when recovery from illness is not expected, death is
anticipated, and focus is on comfort
Hospice careprogram that delivers palliative care to dying individual and
support to dying person and that person’s family and caregivers
Palliative carecare that relieves suffering and provides comfort when
cure is not possible
Rational suicidedecision by competent terminally ill person to end his or
her life
Death is an inevitable, unequivocal, and universal experience, common to

all. Despite the reality that it touches every person’s life at one time or
another, death is difficult for many individuals to face. Although a certainty,
the cessation of life is often dealt with in terms of fury and fear. Humans
can be very reluctant to accept their mortality.
Gerontological nurses commonly face the reality of death because more
than 80% of deaths occur in old age. In addition to facing this reality,
gerontological nurses must learn to deal with the entire dying process—the
complexity of experiences that dying individuals, their family, their friends,
and all others involved with them go through. Working with those who
undergo this complicated process requires a blend of sensitivity, insight, and
knowledge about the complex topic of death in order to diagnose nursing
problems and effectively intervene.
DEFINITIONS OF DEATH
The final termination of life, the cessation of all vital functions, the act or
fact of dying—these are definitions the dictionary offers concerning death
—attempts at succinct explanations of this complex experience. But we are
often reluctant to accept such simple descriptions. For example, the world
of literature contains many eloquent words on the topic of death:
Do not go gentle into that good night

Old age should burn and rave at close of day
Rage, rage against the dying of the light
—Dylan Thomas
Each person is born to one possession which outvalues all the

others—his last breath.
—Mark Twain
Death is fortunate for the child,

bitter to the youth,
too late to the old.
—Publilius Syrus
A man can die but once:

We owe God a death.
—Shakespeare, Henry IV
Current scientific literature does not provide much more in the way of
specific definitions of death. The United Nations Vital Statistics Division
defines death as the cessation of vital functions without capability of
resuscitation. However, terms such as brain death (the death of brain cells
determined by a flat electroencephalogram [EEG]), somatic death
(determined by the absence of cardiac and pulmonary functions), and
molecular death (determined by the cessation of cellular function) confuse
the issue. The controversy lies in deciding at which level of death a person
is considered dead. In some situations, an individual with a flat EEG still
has cardiac and respiratory functions; could this individual be considered
dead? In other situations, individuals with flat EEGs and no
cardiopulmonary functions still have living cells that permit their organs to
be transplanted; are individuals really dead if they possess living cells? The
answers to these questions are not simple. Much current thought and
investigation are focused on the need for a single criterion in the
determination of death.
FAMILY EXPERIENCE WITH THE

DYING PROCESS
In today’s Western culture, many people have very limited experiences with
death or the dying process, but this was not always the case. This change is
due in part to decreases in the mortality rate over the years (Fig. 36-1). In
the past, a higher mortality rate made experiences with the dying process
more common. In addition, there were fewer hospitals and other institutions
in which people could die. Today, health and medical care are easily
available and accessible, and new medications, therapeutic interventions,
and lifesaving technologies have lowered the number of deaths.
FIGURE 36-1 Changes in birth and death rates from 1950

to 2017. (Source: Kochanek, K. D., Murphy, S. L., Xu J.,
& Arias, E. (2019). Deaths: Final data for 2017. National
Vital Statistics Reports , 68 (9). Retrieved from
https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68_09-
508.pdf; Martin, J. A., Hamilton B. E., Osterman M. J. K.,
& Driscoll, A. K. (2019). Births: Final data for 2018.
National Vital Statistics Reports , 68 (13). Retrieved from
https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68_13-
508.pdf )
Perhaps even more significant for limiting exposure to the dying

process are changes in the site and circumstances of death. Previously
viewed as natural processes, most births and deaths were managed by
familiar faces in familiar surroundings. Perhaps the family felt a certain
comfort and closeness by being with and doing for the person whose life
was about to begin or end.
Today, nuclear families are mobile and frequently composed of young
members; older parents and grandparents live in different households, often
in different parts of the country. Furthermore, more deaths occur in an
institutional or hospital setting. Rarely do family and friends remain with
the individual or witness the dying process.
KEY CONCEPT
With fewer people dying at earlier ages than in the past and most deaths
occurring in hospitals or nursing homes, most people have minimal
direct involvement with dying individuals.
The separation of individuals from their loved ones and familiar

surroundings during the dying process seems discomforting, stressful, and
unjust. How inhumane to remove dying persons from intimate involvement
with their support systems at the time of their greatest need for support. As
direct experiences with dying and death are lessened, death becomes a more
impersonal and unusual event. Its reality is difficult to internalize.
Perhaps this explains why many persons have difficulty accepting their
own mortality. Avoiding discussions about death and not making a will or
otherplans related to one’s own death are clues to the lack of internalization
of one’s mortality.
POINT TO PONDER
Do you have a will that outlines your desires for the care of your
children, the distribution of your assets, and your funeral arrangements?
If not, why not?
Nurses who understand their own mortality are more comfortable

helping individuals through the dying process. In denying their own
mortality or feeling angry about it, nurses may tend to avoid dying persons,
discourage their efforts to deal realistically with their death, or instill false
hope in them and their families. The difficult process of confronting and
realizing one’s own mortality need not be viewed as depressing by the
nurse; it can provide a fuller appreciation of life and the impetus for making
the most of every living day.
KEY CONCEPT
Understanding one’s own mortality can be therapeutic to the nurse
personally, as well as helpful in the care of dying patients.
SUPPORTING THE DYING

INDIVIDUAL
For a long time, nurses were more prepared to deal with the care of a dead
body than with the dynamics involved with the dying process. Not only was
open discussion of an individual’s impending death rare but also it was
typical for the dying person to be moved to a separate and often isolated
location during the last few hours of life. If the family was present, they
were frequently left alone with the dying person, without benefit of a
professional’s support. Rather than planning for additional staff support for
the dying person and the family, nurses were concerned with whether a
patient would live until their next shift and require postmortem care. When
death did occur, the body was removed from the unit in secrecy so that
other patients would be unaware of the event. Nurses were discouraged
from showing emotion when a patient died. A detached objectivity was
promoted as part of nursing the dying patient.
Nursing now offers a more humanistic approach to end-of-life care.
Emphasis on meeting the total needs of the patient in a holistic manner has
stimulated greater concern for the psychosocial and spiritual care of the
dying. In addition, there is now recognition that family members and
significant others play a vital role in the dying process and must be
considered by the nurse. Knowledge has increased in the field of
thanatology (i.e., the study of death and dying), and more nurses are
exposed to this body of knowledge. Hospice care, which supports
individuals and their families through the dying process, has developed into
a specialty (Box 36-1). The nursing profession has come to realize that
professionalism does not preclude human emotions in the nurse–patient
relationship. These factors have contributed to increased nursing
involvement with the dying individual.
BOX 36-1 Hospice

Hospice is a way of caring for terminally ill individuals and their
families. Although most hospice care is provided in the home, these
services are required to be provided in nursing home settings also. The
first hospice program was St. Christopher’s Hospice in London. In the
United States, the first hospice began at Hospice, Inc., in New Haven,
Connecticut, in 1974. The National Hospice Organization has developed
standards for hospice care to guide local hospice programs; however,
individuality and autonomy of each program are encouraged.
Hospice care aids in adding quality and meaning into the remaining
period of life. The care involves interdisciplinary efforts to address
physical, emotional, and spiritual needs, including:
pain relief
symptom control
home care and institutional care coordinated among an
interdisciplinary team
social work and counseling services
medical equipment and supplies
volunteer assistance and support
bereavement follow-up and counseling
For more information, contact the National Hospice & Palliative

Care Organization (NHPCO), 1731 King Street, Alexandria, VA 22314,
703-837-1500, http://www.nhpco.org.
Because the dying process is unique for every human being,

individualized nursing intervention is required. Patients’ previous
experiences with death, religious and spiritual beliefs, philosophy of life,
age, and health status are among the multitude of complex factors affecting
the dying process. Table 36-1 lists a variety of problems related to death and
dying along with contributing factors. The nurse must carefully assess the
particular experiences, attitudes, beliefs, and values that each individual
brings to his or her dying process. Only through this assessment can the
most therapeutic and individualized support be given to the dying person.
TABLE 36-1 Nursing Problems Related to Death and Dying

Depression, anxiety, fear, and isolation are all characteristics of an aging
client with altered thought processes. Deficient knowledge is not typically
associated with altered thought processes or fear.
KEY CONCEPT
Patients’ reactions to dying are influenced by previous experiences with
death, age, health status, philosophy of life, and religious, spiritual, and
cultural beliefs.
>
Recall from
Chapters 3 and 8 Julia Morales, who made the decision supported by her
partner, Lucy, to stop treatment for lung cancer. How would the nurse
introduce and explain hospice care as an option for Julia? How can the
nurse collaborate with the interprofessional team to promote dignified end-
of-life care? What steps would the nurse take to ensure that Julia’s and
Lucy’s decisions about treatment are respected by all health care team
members?
Stages of the Dying Process and Related Nursing
Interventions
Although the dying process is a unique journey for each individual,
common reactions that have been observed to occur provide a basis for
understanding the process. After several years of experiences with dying
patients, Elisabeth Kübler-Ross developed a conceptual framework
outlining the coping mechanisms of dying in terms of five stages that has
now become classic (Kübler-Ross, 1969; Kübler-Ross & Kessler, 2014). It
behooves the nurse to be familiar with these stages and to understand the
most therapeutic nursing interventions during each stage. Not all dying
persons will progress through these stages in an orderly sequence. Neither
will every dying person experience all of these stages. However, an
awareness of Kübler-Ross’ conceptual framework can help the nurse
support dying individuals as they demonstrate complex reactions to death.
A brief description of these stages, along with pertinent nursing
considerations, follows.
Denial
On becoming aware of their impending death, most individuals initially
react by denying the reality of the situation. “It isn’t true” and “There must
be some mistake” are among the comments reflective of this denial.
Patients sometimes “shop” for a physician who will suggest a different
diagnosis or invest in healers and fads that promise a more favorable
outcome. Denial serves several useful purposes for the dying person. It is a
shock absorber after learning the difficult news that one has a terminal
condition, it provides an opportunity for people to test the certainty of this
information, and it allows people time to internalize the information and
mobilize their defenses.
Although the need is strongest early on, dying persons may use denial
at various times throughout their illness. They may fluctuate between
wanting to discuss their impending death and denying its reality. Although
such a contradiction may be confusing, the nurse must be sensitive to the
person’s need for defenses while also being ready to participate in
discussions on death when the person needs to do so. The nurse should try
to accept the dying person’s use of defenses rather than focus on the
conflicting messages. An individual’s life philosophy, unique coping
mechanisms, and knowledge of the condition determine when denial will be
replaced by less radical defense mechanisms. Perhaps the most important
nursing action during this stage is to accept the dying individual’s reactions
and to provide an open door for honest dialogue.
Anger
The stage of denial and the “No, not me” reaction is gradually replaced by
one of “Why me?” This second stage, anger, is often extremely difficult for
individuals surrounding the dying person because they are frequently the
victims of displaced anger. In this stage, the dying person expresses the
feeling that nothing is right. For example, nurses do not answer the call
light soon enough, the food tastes awful, the doctors do not know what they
are doing, and visitors either stay too long or not long enough. Seen through
the eyes of the dying person, such anger is understandable. Why wouldn’t
people resent not having what they want when they want it when they don’t
have much time? Why wouldn’t they be envious of those who will enjoy a
future they will never see? Their unfulfilled desires and the unfinished
business of their life may cause outrage. Perhaps their complaints and
demands are used to remind those around them that they are still living
beings.
During this time, the family may feel guilt, embarrassment, grief, or
anger in response to the dying person’s anger. They may not understand
why their intentions are misunderstood or their actions unappreciated. It is
not unusual for them to question whether they are doing things correctly.
The nurse should help the family gain insight into the individual’s behavior,
which can relieve their discomfort and, thus, create a more beneficial
environment for the dying person. If the family can come to realize that the
person is reacting to impending death and not to them personally, it may
facilitate a more supportive relationship.
The nurse should also guard against responding to the dying person’s
anger as a personal affront. The best nursing efforts may receive criticism
for not being good enough; cheerful overtures may be received with scorn;
the call light goes on the minute the nurse leaves the room. It is important
that the nurse assess such behavior and understand that it may reflect the
anger of the second stage of the dying process. Instead of responding to the
anger, the nurse should be accepting, implying to the dying person that it is
fine to vent these feelings. Anticipating needs, remembering favorite things,
and maintaining a pleasant attitude can counterbalance the anticipated
losses that are becoming more apparent to the dying individual. It may be
useful for nurses to discuss their feelings about the patient’s anger with an
objective colleague who can serve as a sounding board so that the nurse–
patient relationship continues to be therapeutic.
Bargaining
After recognizing that neither denial nor anger changes the reality of
impending death, dying persons may attempt to negotiate a postponement
of the inevitable. They may agree to be a better Christian if God lets them
live through one more Christmas; they may promise to take better care of
themselves if the physician initiates aggressive therapy to prolong life; they
may promise anything in return for an extension of life. Most bargains are
made with God and usually kept a secret. Sometimes such agreements are
shared with members of the clergy. The nurse should be aware that dying
persons may feel disappointed at not having their bargain honored or guilty
over the fact that, having gained time, they want an additional extension of
life even though they agreed that the request would be their last. It is
important that these often covert feelings be explored with the dying
person.
Depression
When a patient is hospitalized with increasing frequency and experiences
declining functional capacity and more symptoms, the reality of the dying
process is emphasized. The older patient may already have had many losses
and experienced depression. Not only may lifetime savings, pleasurable
pastimes, and a normal lifestyle be gone but also bodily functions and even
body parts may be lost. Understandably, all this may lead to depression.
Unlike other forms of depression, however, the depression of the dying
person may not benefit from encouragement and reassurances. Urging
dying persons to cheer up and look at the sunny side of things implies that
they should not contemplate their impending death. It is unrealistic to
believe that dying people should not be deeply saddened by the most
significant loss of all—their life.
The depression of the dying person is usually a silent one. It is
important for the nurse to understand that cheerful words may be far less
meaningful to dying individuals than holding their hand or silently sitting
with them (Fig. 36-2). Being with the dying person who openly or silently
contemplates the future is a significant nursing action during this stage. An
interest in prayer and a desire for visits from clergy are commonly seen
during this stage. The nurse should be particularly sensitive to the dying
person’s religious needs and facilitate the clergy–patient relationship in
every way possible.
FIGURE 36-2 Touching, comforting, and being near the

dying individual are significant nursing actions.
The nurse may need to help the family understand this depression,
explaining that their efforts to cheer the dying person can hinder rather than
enhance the patient’s emotional preparation. The family may require
reassurance for the helplessness they feel at this time. The nurse may
emphasize that this type of depression is necessary for the individual to be
able to approach death in a stage of acceptance and peace.
Acceptance
For many dying persons, a time comes when the struggling ends and relief
ensues. It is as though a final rest is being taken to gain the strength for a
long journey. This acceptance should not be mistaken for a happy state; it
implies that the individual has come to terms with death and has found a
sense of peace. During this stage, patients may benefit more from nonverbal
than verbal communication. It is important that their silence and withdrawal
not result in isolation from human contact. Touching, comforting, and being
near the person are valuable nursing actions. An effort to simplify the
environment may be required as the dying person’s circle of interests
gradually shrinks. It is not unusual for the family to need a great deal of
assistance in learning to understand and support their loved one during this
stage.
Significantly, hope commonly permeates all stages of the dying process.
Hope can be used as a temporary but necessary form of denial, as a
rationalization for enduring unpleasant therapies, and as a source of
motivation. It may provide a sense of having a special mission to comfort
an individual through the last days. A realistic confrontation of impending
death does not negate the presence of hope.
KEY CONCEPT
The five stages of the dying process include denial, anger, bargaining,
depression, and acceptance.

There has been growing acceptance of rational suicide , a situation in
which a competent adult makes a reasoned decision to die by suicide while
he or she is cognitively intact and relatively free from pain (Gramaglia,
Calati, & Zeppegno, 2019), as well as assisted suicide , in which an
individual who has decided to end his or her life does so with the aid of
another person. In fact, assisted suicide has become legal in some states
(e.g., California, Colorado, Oregon, Vermont, Washington); it is sometimes
done with the assistance of a medical professional, who may advise the
person about lethal doses of drugs or who may supply these drugs. It can be
argued that to prevent a rational person who does not see the meaning to life
or who is near the end of life from committing suicide shows no respect for
the person’s autonomy in making his or her own health care decisions
(Dugdale, Lerner, & Callahan, 2019). Although an individual can present
suicide as a reasoned choice, suicide plans should not be accepted without
some exploration of the factors that led to this decision.
COMMUNICATION TIP
When a competent individual with no psychiatric history has
expressed plans for suicide, even when at the end of life, it is
beneficial to ask the person questions such as:
Why are you making this choice?

What concerns do you have? Do you have concerns such as that
you’ll have pain that won’t be able to be controlled, that you’ll be
a burden to your family, or that your dying process won’t be
handled as you would want?
Do you have plans for carrying this out and, if so, what are they?
Is there someone who has agreed to help you carry this out?
The questioning and discussion should be conducted without implying

a judgment about the person’s decision.
The responses should be documented and discussed with the
interdisciplinary team. The fact that the person may have a reasonable
justification for suicide doesn’t mean that counseling, support, and the
provision of services to aid with care couldn’t improve the person’s
emotional well-being and quality of life sufficiently to change his or
her view.
If there is any question that the person is not thinking rationally, or if
there are signs of depression, promptly alert the medical provider and
discuss the need for suicide precautions. Just because a person is near
the end of life does not mean that suicide is the best decision.

Pain
Concern regarding the degree of pain that will be experienced and its
management may be a considerable source of distress for dying individuals;
nurses can reduce distress for patients by supplying them with realistic
information regarding pain. Patients with cancer are more likely to
experience severe pain than persons dying from other causes, and even
among terminally ill cancer patients, pain can be managed effectively.
Gerontological nurses must be aware that patients will perceive and
express pain differently based on their medical diagnosis, emotional state,
cognitive function, and other factors. Complaints of pain or discomfort,
nausea, irritability, restlessness, and anxiety are common indicators of pain;
however, the absence of such expressions of pain does not mean it does not
exist. Some patients may not overtly express their pain; in these individuals,
signs such as sleep disturbances, reduced activity, diaphoresis, pallor, poor
appetite, grimacing, and withdrawal may provide clues to the presence of
pain. In some circumstances, confusion can be associated with pain.
Palliative care is care that prevents and relieves pain in persons with
incurable conditions. Although palliative care can be provided to persons
who are not dying, it is an important element in the care of dying
individuals. Nurses must regularly assess pain because it can increase or
decrease over time. Patients should be encouraged to report their pain in a
timely manner and openly discuss their concerns about pain. It can be
useful for patients to rate their pain on a scale of 0 to 10 (0 being no pain
and 10 the most severe pain); nursing staff can record patients’ self-
appraisal of pain along with other factors on a flow sheet.
For the dying patient, the goal of pain management is to prevent pain
from occurring rather than to respond to it after it occurs. Pain prevention
not only helps patients avoid discomfort but also ultimately reduces the
amount of analgesics they use. After the pattern of pain has been assessed, a
schedule for the administration of analgesics can be developed. The type of
analgesic used will depend on the intensity of the pain, ranging from aspirin
or acetaminophen for mild pain to codeine or oxycodone for moderate pain
to morphine or hydromorphone for severe pain. Meperidine and
pentazocine are contraindicated for pain control in older adults because of
their high incidence of adverse effects, particularly psychosis, at relatively
low dosages. Nurses should note and instruct patients to report
ineffectiveness of analgesics or their schedule of administration,
overdosage, and adverse reactions (Box 36-2).
BOX 36-2 Pain Management for the Dying

Patient
Mr. Lugio is a terminally ill nursing facility resident who is suffering
from pain secondary to metastasis of his lung cancer to his spine. His
pain has been managed with a nonsteroid anti-inflammatory drug that he
receives PRN, but nursing staff feel that the drug may be ineffective
because Mr. Lugio is seen grimacing with pain periodically throughout
the day. A review of his medication administration record reveals that he
sometimes asks for his pain medication at 6- to 8-hour intervals,
although he is able to have the drug every 4 hours. The nurses observe
that he complains of pain more frequently during the week than on
weekends when his family visits.
Nursing staff could consider the following in helping to achieve
improved pain control for Mr. Lugio:
Assess the pattern and severity of pain. Provide Mr. Lugio with a
chart to record his pain. Instruct him to rate his pain on a scale of 0
to 10, in which 0 indicates no pain and 10 indicates severe pain.
Analyze the pattern.
Recommend that Mr. Lugio take his analgesic on a regular basis
rather than sporadically. Rather than change the type or dosage of
analgesic at this time, determine if a regular schedule of
administration could improve pain control. Often, regularly
scheduled doses can maintain an analgesic level that prevents pain
and provides greater relief. If regularly scheduled doses prove
ineffective, a change in dosage or the type of analgesic can be
considered.
Assess Mr. Lugio’s understanding of analgesic use. He should
understand that addiction or “overuse” of the analgesic is not a
primary concern and be encouraged to inform nursing staff of the
need for pain relief when necessary.
Consider the impact of psychological factors on his physical pain.
The worsening of his pain when his family is not present could be
related to anxiety, boredom, or other psychosocial factors.
Psychosocial discomfort can intensify or exacerbate physical
discomfort. Mr. Lugio may benefit from a listening ear, counseling,
diversional activities, or more frequent visits from his family.
Use nonpharmacologic pain relief measures. Back rubs, therapeutic
touch, guided imagery, relaxation exercises, and counseling could
prove effective in managing pain. Trained practitioners could
provide acupressure, acupuncture, and hypnosis. These measures
should be reviewed with the physician.
KEY CONCEPT
For the dying patient, the goal of pain management is to prevent pain
from developing rather than treat it once it occurs.
Alternatives to medications should be included in the pain control

program of dying patients. Such measures include guided imagery,
hypnosis, relaxation exercises, massage, acupressure, acupuncture,
therapeutic touch, diversion, and the application of heat or cold. Even if
these measures cannot substitute for medications, they could reduce the
amount of drugs used or potentiate the drugs’ effects.
Respiratory Distress
Respiratory distress is a common problem in dying patients. In addition to
the physical discomfort resulting from dyspnea, patients can experience
tremendous psychological distress associated with the fear, anxiety, and
helplessness that results from the thought of suffocating. The causes of
respiratory distress can range from pleural effusion to deteriorating blood
gas levels. Interventions such as elevating the head of the bed, pacing
activities, teaching the patient relaxation exercises, and administering
oxygen can prove beneficial. Atropine or furosemide may be administered
to reduce bronchial secretions; narcotics may be used for their ability to
control respiratory symptoms by blunting the medullary response.
Constipation
Reduced food and fluid intake, inactivity, and the effects of medications
cause constipation to be a problem for most dying patients—a problem that
can add to the discomfort these patients already are experiencing. Knowing
that the risk of this problem is high, nursing staff should take measures to
promote regular bowel elimination in terminally ill patients. Increasing
activity and the intake of fluids and fibers are beneficial. Laxatives usually
are administered on a regular schedule, and bowel elimination patterns
should be recorded and assessed. It must be remembered that what may
appear to be diarrhea may actually be seepage of liquid wastes around a
fecal impaction.
Poor Nutritional Intake

Many dying patients experience anorexia, nausea, and vomiting that can
prevent the ingestion of even the most basic nutrients. Additionally, fatigue
and weakness can make the act of eating a monumental task. Serving small-
portioned meals that have alluring appearances and aromas can stimulate
the appetite, as can providing foods that are patients’ favorites. An alcoholic
drink before meals can boost the appetite of some persons. Nausea and
vomiting can be controlled with the use of antiemetics and antihistamines;
ginger has been used successfully by many individuals as a natural
antiemetic. Also useful are basic nursing measures, such as assisting with
oral hygiene, offering a clean and pleasant environment for dining,
providing pleasant company during mealtime, and assisting with feeding as
necessary.
KEY CONCEPT
The herb ginger has been effective in controlling nausea for some
individuals without the side effects of antiemetic drugs.

Americans hold a diversity of religious beliefs. Each religion has its own
practices related to death, and nursing staff must respect these practices to
promote the fulfillment of patients’ spiritual needs. Table 36-2 lists some
basic differences among religions in beliefs and practices related to death.
Nursing staff must be sensitive to differences and ensure that they do not
inadvertently disrespect the religious beliefs of patients and their families.
TABLE 36-2 Religious Beliefs and Practices Related to Death
Because it is likely that the importance of religion in patients’ lives as

they are dying will be a reflection of the role of religion throughout their
lives, assessment should explore not only their religious affiliation but also
their individual religious practices. Furthermore, nurses must recognize that
religion and spirituality are not synonymous (see Chapter 30). Religion is
but one aspect of spirituality; patients can be highly spiritual without
religious affiliation. To determine the significance of spirituality and the
spiritual needs of patients, nurses can ask questions such as the following:
What gives you the strength to face life’s challenges?

Do you feel a connection with a higher being or spirit?
What gives your life meaning?
Clergy and congregation members of the faith group to which the

patient belongs should be invited to be actively involved with the patient
and family, according to their wishes. If nursing staff feel comfortable with
the practice, they can offer to pray with patients or read to them from
religious texts; of course, nursing staff should ensure that prayers offered
are consistent with a patient’s belief system.

When death is near, bodily functions will slow and certain signs and
symptoms will occur, including:
decline in blood pressure

rapid, weak pulse
dyspnea and periods of apnea
slower or no pupil response to light
profuse perspiration
cold extremities
bladder and bowel incontinence
pallor and mottling of skin
loss of hearing and vision
Identifying the approach of death enables nursing staff to assure family

is notified and given the opportunity to share the last minutes of the
patient’s life. If the family is unavailable, a staff member should remain
with the patient. Depending on the wishes of the patient and family, clergy
may be called to visit the patient at this time. It is important that the patient
not be alone during this period; even if it appears that the patient is
unresponsive, he or she should be spoken to and touched.
Advance Directives
A patient can express desires regarding terminal care and life-sustaining
measures through the legal document of an advance directive. All health
care facilities and agencies that receive Medicare and Medicaid funding
must provide information to patients about the Patient Self-Determination
Act, which gives individuals the right to express their choice regarding
medical and surgical care and to have those preferences honored at a later
time if they are unable to communicate it. Nurses should review this issue
with patients as they are admitted to a hospital or nursing home setting and
discuss the importance of the patient expressing his or her desires in a
legally sound manner. For many older adults and their families, discussing
issues pertaining to dying is uncomfortable; by introducing and guiding the
discussion with sensitivity, nurses can assist older adults in confronting
these important issues, and assuring their wishes are known. If an advance
directive exists, the nurse should review it with the patient to assure it
continues to reflect the patient’s preference and place a copy in the medical
record to inform all members of the interdisciplinary team. (Chapter 8
provides more discussion on legal issues pertaining to death and dying.)
Some states have implemented the use of MOLST (Medical Orders for
Life-Sustaining Treatments) forms and POLST (Physician Orders for Life-
Sustaining Treatments) forms. Through conversations with health care
professionals involved in their care, individuals with serious illnesses or
who are near the end of life develop these documents to describe specific
medical treatments that they wish to have during a medical emergency.
These documents differ from advance directives in that they are not legal
documents that describe desired future care, nor do they contain
information as to surrogates who can make medical decisions on their
behalf. Even if individuals have MOLST or POLST forms, they still should
have an advance directive.
KEY CONCEPT
An advance directive protects the patient’s right to make decisions about
terminal care and eases some of the burden of family members during
this difficult time.
SUPPORTING FAMILY AND FRIENDS

Thomas Mann’s comment that “a man’s dying is more the survivors’ affair
than his own” is a reminder that the family and friends need to be
considered in the nursing care of the dying person. They too may have
needs requiring therapeutic intervention during the dying process of their
loved one. Offering appropriate support throughout this process may
prevent unnecessary stress and provide immense comfort to those involved
with the dying person.
Supporting Through the Stages of the Dying

Process
Just as dying persons experience different reactions as they cope with the
reality of their impending death, so may family and friends pass through the
stages of denial, anger, bargaining, and depression before they are ready to
accept the fact that a special person in their lives is going to die.
In the denial stage, family and friends may discourage patients from
talking or thinking about death; visit patients less frequently; state that
patients will be better as soon as they return home, start eating, have their
intravenous tube removed, and so forth. They may shop around for a doctor
or hospital to find a special cure for the terminal illness.
Reactions during the anger stage may include criticizing staff for the
care they are giving, reproaching a family member for not paying attention
to the patient’s problem earlier, and questioning why someone who has led
such a good life should have this happen.
Family and friends may try to bargain to avoid or delay their loved
one’s death. They may tell the staff that if they could take the patient home
they know they could improve his or her condition. Through prayers or
open expression they may agree to take better care of the patient if given
another chance. They may consent to some particular action (e.g., going to
church regularly, volunteering for good causes, or giving up drinking) if
only the patient could live to a particular time.
When entering the depression stage, family and friends may become
more dependent on the staff. They may begin crying and limiting contact
with the patient.
In the acceptance stage, people may react by wanting to spend a great
deal of time with the dying person and telling the staff of the good
experiences they have had with the patient and how they are going to miss
the person. They may request the staff to do special things for the patient
(e.g., arrange for favorite foods, eliminate certain procedures, and provide
additional comfort measures). They may frequently remind the staff to be
sure to contact them “when the time comes.” They may begin making
specific arrangements for their own lives without the patient (e.g., change
of housing, plans for property, and strengthening other relationships for
support).
Obviously, the type of nursing support will vary depending on the stage
at which a family member or friend is assessed to be. Although the nursing
actions described for the dying individual during each stage may be
applicable for family and friends, the stages experienced by those involved
with the dying person may not coincide with the patient’s own timetable for
these stages. For instance, patients may already have worked through the
different stages, come to accept the reality of death, and be ready to openly
discuss the impact of their death and make plans for their survivors.
However, family members and friends may be at different stages and not be
able to deal with the patient’s acceptance. The nurse must be aware of these
discrepancies in states and provide individualized therapeutic interventions.
While providing appropriate support to family and friends as they pass
through the stages, the nurse can offer opportunities for dying people to
discuss their death openly with a receptive party.
CONSIDER THIS CASE

Seventy-year-old Mr. Angelos has a rare
liver cancer. He is widowed and lives with his daughter and her family.
The chemotherapy that he has been receiving has left him so weak and
uncomfortable that he spends most of his time heavily medicated, lying on
the sofa or sleeping in bed.
During today’s office visit, the oncologist informs Mr. Angelos and his
daughter that the chemotherapy is not controlling the cancer; it is rapidly
metastasizing. He recommends that home hospice care be initiated. Before
Mr. Angelos can respond, his daughter abruptly ends the visit, stating, “We
don’t have to discuss this now. Let us think about this.” She then motions
her father to leave with her.
While in the outer office preparing to leave, the daughter shares with
the nurse that she “can’t understand where that doctor is coming from,
basically giving up on my father.” Mr. Angelos interjects that he thinks the
doctor is right, but his daughter cuts him off, stating, “Dad, you are going
to beat this thing. It just takes time for chemo to work. And, there are other
treatments we can try.”
THINK CRITICALLY
1. What reactions are Mr. Angelos and his daughter each
displaying? Why?
2. What response can the nurse offer?

3. What are the potential outcomes of this situation?

When patients die, it is useful for the nurse to be available to provide any
needed support to family and friends. Some people wish to have several
minutes in private with deceased patients to view and touch them. Others
want the nurse to accompany them as they visit the deceased. Still others
may not want to enter the room at all. Nurses must respect the personal
desires of the family and friends and be careful not to make value
judgments of the family’s reaction based on their own attitudes and beliefs.
It is beneficial to encourage the family and friends to express their grief
openly. Crying and shouting may help people cope with and work through
their feelings about the death more than suppressing their feelings to
achieve a calm composure.
Funeral and burial arrangements may require guidance by a
professional. The survivors of the deceased may be experiencing grief,
guilt, or other reactions that place them in a vulnerable position. At this
time, they are especially susceptible to sales pitches equating their love for
the deceased to the cost of the funeral. The family may need to have the
extravagant plans presented by a funeral director counterbalanced by
realistic questions concerning the financial impact of such a funeral.
Whether it is the nurse, a member of the clergy, or a neighbor, it is valuable
to identify some person who can be an advocate for the family at this
difficult time and prevent them from being taken advantage of. People
should be encouraged to learn about the funeral industry and plan in
advance for funeral arrangements. In addition to books on the topic, a
number of memorial societies can assist individuals in their planning.
After the agitation of the funeral has diminished and fewer visitors are
calling to pay their respects, the full impact of the death may first be
realized. At the time when the most intense grief occurs, fewer resources
may be available to provide support. The gerontological nurse can arrange
for a visiting nurse, a church member, a social worker, or someone else to
check on the family members several weeks after the death to make sure
they are not experiencing any crisis. Widow-to-widow and similar groups
can support individuals through the grieving process. It may also be
beneficial to provide the telephone number of a person whom the family
can contact if assistance is required.
SUPPORTING NURSING STAFF

The staff members working with the dying individual have their own set of
feelings regarding this significant experience. It may be extremely difficult
for staff not only to accept a particular patient’s death but also to come to
terms with the whole issue of death. Some nursing staff share the difficulty
that many persons have in realizing their own mortality. Their experiences
with death may be limited, as may their exposure to the subject through
formal education. In a health profession in which the emphasis is primarily
on “curing,” death may be viewed as a dissatisfying failure. Nursing staff
may feel powerless as they realize that their best efforts can do little to
overcome the reality of impending death. It is not unusual for a nursing
caregiver who is involved with a dying patient to also experience the stages
of the dying process described by Elisabeth Kübler-Ross. Staff members are
commonly observed to avoid contact with dying patients, tell a patient to
“cheer up” and not think about death, continue to practice “heroic”
measures although a patient is nearing death, and grieve at the death of a
patient. Nursing staff may be limited in their ability to support patients and
their families if they are at a different stage from them.
The staff working with a dying patient requires a great deal of support.
Colleagues should help coworkers explore their own reactions to dying
patients and recognize when those reactions interfere with a therapeutic
nurse–patient relationship. The attitude of colleagues and the environment
should be such that nursing staff can retreat from a situation that is not
therapeutic either for them or for the patient. To encourage the nurse to cry
or show emotions in other forms may be extremely beneficial. The use of
thanatologists, hospice staff, and other resource people may also be
valuable in providing support to nurses as they assist an individual through
the dying process.
KEY CONCEPT
Nursing staff should be encouraged to express their own feelings about
patients’ deaths.
Is the Bereavement Grief Intensity of Survivors

Linked With Their Perception of Death Quality?
Source: Wilson, D. M., Cohen, J., Eliason, C., Deliens, L., Macleod, R.,
Hewitt, J. A., & Hourrekier, D. (2019). International Journal of Palliative
Nursing, 25(8), 398–405.
Many factors could contribute to how an individual experiences grief.
This pilot study explored the possible relationship between the perceived
quality of the dying experience and the bereavement grief intensity.
Persons who suffered the loss of a loved one completed a questionnaire
that collected data on perceived death quality, bereavement grief intensity,
and the personal characteristics of the deceased individual and the bereaved
person. An analysis of the data revealed that over half of the respondents
experienced high levels of grief; they rated the death experience as more
bad than good. There was a negative correlation between death quality and
postdeath grief intensity (i.e., the lower the quality of the death experience,
the higher the postdeath grief).
Although many factors affect grief (e.g., age of deceased, quality of
relationship between the deceased and the bereaved person, suffering during
the dying experience, unresolved conflict, expectation of death) that nurses
may be limited in their ability to change, the quality of the dying experience
could be impacted significantly by nursing actions. The sensitivity,
patience, and efforts of nurses as they care for the dying individual and his
or her family form a significant last memory that could affect the intensity
of the survivors’ grief and their emotional healing from the experience.
Even small efforts can affect survivors’ perception of the dying experience.
Nurses should remember that the effective nursing care at the end of life not
only enables the individual to die with peace, comfort, and dignity but
could have an impact on the health and quality of life of the survivors.
PRACTICE REALITIES
Seventy-eight-year-old Mr. Harod has been a long-term resident of a
retirement community. Although mentally sharp, his physical condition has
declined in the past several months and he has been diagnosed with
pancreatic cancer. He has declined treatment, stating that he understands his
poor prognosis and would rather spend whatever life he has left unbothered
by the stress and side effects of treatment.
Last month Mr. Harod was transferred to the nursing home section of
the retirement community. You have noticed several individuals regularly
visiting him and learn from another resident that these people are part of a
group who support assisted suicide.
A few days later, when entering Mr. Harod’s room for morning rounds,
you find him deceased. By his bed are several papers that describe who to
contact and what plans to make. You are aware that the people who had
been visiting had been there the evening before and spent considerable time
in a private meeting with Mr. Harod.
One of the residents comments that Mr. Harod “went out on his own
terms.” It appears several of the residents support his choice; it was, in fact,
suicide.
What should you do in this situation?

1. Discuss factors that cause Americans to have difficulty discussing and
planning for death.
2. In addressing a group of older adults at a senior citizen center, what
examples could you offer to support the benefits of developing an
advance directive?
3. State some examples of behaviors that could demonstrate reactions of
nursing staff to the death of a long-term patient.
Chapter Summary
Due to the reality that a majority of deaths occur among older adults,
gerontological nurses will need competency in assisting individuals with the
dying process. A holistic approach—in which the nurse assures that the
dying individuals and their loved ones are provided physical, emotional,
and spiritual support—is needed. Patients’ previous experiences with death,
religious and spiritual beliefs, philosophy of life, age, and health status are
among the multitude of complex factors that must be considered in
providing support and care.
Kübler-Ross has offered a conceptual framework for understanding the
coping mechanisms during the dying process. Not all dying persons will
experience all the stages outlined nor will they progress through these
stages in an orderly sequence. Nurses should be familiar with interventions
that are appropriate for each stage.
In recent years, there has been growing acceptance of rational suicide,
whereby a competent adult makes a reasoned decision to die by suicide
while he or she is cognitively intact and relatively free from pain, as well as
assisted suicide. Although increasingly accepted and occurring, a patient’s
decision to put an end to his or her life demands exploration and
assessment. There is the possibility that counseling, support, and the
provision of services to aid with care could improve emotional well-being
and quality of life sufficiently to change the individual’s view.
As death nears, physical care needs must be addressed, including pain
management, prevention and relief of respiratory distress, provision of
adequate intake, and prevention and management of constipation. Spiritual
needs also must be considered and supported, recognizing that religion is
one aspect of spirituality, individuals of the same faith can practice that
faith differently, and that patients can be highly spiritual without religious
affiliation.
As death nears, bodily functions slow and certain signs and symptoms
appear, including decreased blood pressure, rapid weak pulse, dyspnea,
periods of apnea, slow or no pupil response to light, cold extremities,
incontinence, pallor and mottling of the skin, and loss of hearing and vision.
The family should be notified so that they can share the last minutes of the
patient’s life; if they are not available, a staff member should remain with
the patient.
Family and friends of the dying individual, who can experience
considerable distress, may benefit from support and referral to support
groups. Likewise, staff members who cared for the dying patient may
experience grief and may benefit from support.
Online Resources
AARP Advance Directive Forms (by State)
https://www.aarp.org/caregiving/financial-legal/free-printable-advance-
directives/
American Hospice Foundation
http://www.americanhospice.org
End of Life/Palliative Education Resource Center
https://waportal.org/resources/end-life-palliative-education-resource-center
Family Hospice & Palliative Care
http://www.familyhospice.com
Hospice Foundation of America
http://www.hospicefoundation.org
International Association for Hospice & Palliative Care
http://www.hospicecare.com
National Hospice and Palliative Care Organization
http://www.nhpco.org
References
Dugdale, L. S., Lerner, B. H., & Callahan, D. (2019). Pros and cons of physician aid in dying. Yale
Journal of Biology and Medicine, 92 (4), 747–750.
Gramaglia, C., Calati, R., & Zeppegno, P. (2019). Rational suicide in late life: A systematic review of
the literature. Medicina, 55 (10), 656. doi: 10.3390/medicina55100656.
Kübler-Ross, E. (1969). On death and dying. New York, NY: Macmillan.
Kübler-Ross, E., & Kessler, D. (2014). On grief and grieving. Finding meaning of grief through the
five stages of loss. New York, NY: Scribner.
Appendix A Next Generation
NCLEX-Style Case Studies and
Questions
Chapter 11: Nutrition and
Hydration
STEP 1
A 68-year-old female client presents to the weight management clinic for
her obesity.
Nurse’s
Notes
1000: The client indicates that she has gained 50 lb since she retired last
year from her job. She further states that she cannot understand why she has
gained this weight since she only eats one meal a day. She says, “I have not
been exercising like I should since my gym membership was discontinued
because I was not able to pay for it.”
counter multivitamin and a weight management herbal supplement that her
sister gave her. She has lost her appetite since taking the herbal supplement
but has not lost weight.
The client smokes half a pack of cigarettes a day and has smoked for 20
years; she drinks 3 glasses of red wine daily and 5 cups of coffee daily
because she hates drinking water. Her last dental visit was 2 years ago, and
she indicates that she has no money to visit the dentist. Vital signs:
temperature 98.6 oral, pulse 110, respiration 20, and BP 140/80. Weight is
250 lb and height is 5′8″, with a BMI of 35.9%. The last bowel movement
was 3 days ago. The nurse draws the client’s blood and sends it out to the
lab for CBC (complete metabolic profile), hemoglobin A1c, fasting
cholesterol level, and liver function test. The bedside glucose test result was
74 fasting. The client declines order for a nicotine patch to stop smoking
and states that she will work on decreasing her coffee and wine
consumption.
Identify the top 4 client findings that would require follow-up.

STEP 2
Nurse’s
Notes
1000:
The client indicates that she has gained 50 lb since she retired last year from
her job. She further states that she cannot understand why she has gained
this weight since she only eats one meal a day. She says, “I have not been
exercising like I should since my gym membership was discontinued
consumption.
For each finding below, check the appropriate box to indicate if the finding
is consistent with the characteristics and effects of the provided outcomes.
Each finding may support more than one outcome.
Note: Each column must have at least 1 response selected.
STEP 3
Nurse’s
Notes
1000:
consumption.
Complete the following sentence by selecting the correct options from the
list.
The factors contributing to the client’s diagnosis of hypertension include
(list 1) , (list 1), and (list 1).
STEP 4
Nurse’s
Notes
1000: .
consumption.
1200: The nurse provides discharge instructions to the client after receiving
the primary health care provider’s order. The nurse instructs the client to
start keeping a food intake journal, limit dietary fat intake to less than 30%,
limit fried foods, consume at least 1 g protein per kilogram of body weight,
eat at least five servings of fruits and vegetables daily, and drink at least 11
glasses of water a day. The nurse makes an appointment for a registered
dietitian consult for the client and advises client to increase her social
outings and to walk 30 minutes daily 4 times a week. The client is
scheduled to return in 2 weeks for a follow-up appointment.
The nurse has reviewed the Nurses’ Notes entries from 1000 and 1200. For
each potential nursing intervention, check the appropriate box to indicate if
the intervention is indicated or nonessential for the client.
STEP 5
Nurse’s
Notes
1000:
consumption.
Complete the following sentence by choosing from the lists of options.

After receiving orders from the health care provider, the nurse should have
given priority to implementing (list 1) and then (list 2) to best ensure client
success with achieving desired outcomes.
STEP 6
Nurse’s
Notes
1000:
consumption.
1215:
Orders
The client returns for the scheduled 2 week follow-up. A physical and
emotional assessment is completed and documented.
What nursing assessment data support the conclusion that the client’s
physical and emotional health is demonstrating improvement? (Select all
that apply.)
□ 1. BP: 130/76
□ 2. Weight: 243 lb
□ 3. Fasting glucose fingerstick: 80 mg/dL
□ 4. Client states, “I’ve started wearing a nicotine patch.”
□ 5. Respirations: 12 breaths/min
□ 6. Client states, “I walk sometimes, but I really don’t enjoy it.”
□ 7. Client reports eating a fresh salad for lunch most days.
STEP 1
The nurse is caring for a 72-year-old male resident who lives in a long-term
care facility.
Nurse’s
Notes
0830: The nurse notes during breakfast in the dining room that the resident
is nodding off with his meal untouched. When awakened, he becomes
frustrated and combative, saying, “Leave me alone; I don’t sleep at night.”
The nurse encourages him to stay awake and finish eating his breakfast.
The resident indicates that he finds it difficult to fall asleep because his
legs keep jerking and he has an uncontrollable urge to move his legs. He
says that when he finally falls asleep, he is awakened with an urge to use
the bathroom because of the water pills he takes. Upon assessment, the
resident says, “I only sleep about 2 hours a night.”
furosemide twice a day (9 am and 9 pm) for congestive heart failure (CHF)
as evidenced by his shortness of breath (SOB); the resident gets only 2
hours of quality sleep every night; the resident drinks 1 cup of caffeinated
coffee at 6 pm every evening and is frequently observed falling asleep at
meals.
Identify the top 4 assessment findings that would require follow-up.

STEP 2
care facility.
Nurse’s
Notes
meals.
For each finding below, check the appropriate box to indicate if the
finding is consistent with the characteristics for each sleep Impairment.
Each finding may apply to more than one sleep Impairment.
STEP 3
care facility.
Nurse’s
Notes
meals.
Complete the following sentence by selecting the correct options from each
list.
The resident’s general health will be most negatively impacted by his risk
for developing (list 1) as evidenced by the resident’s (list 2) .
STEP 4
care facility.
Nurse’s
Notes
meals.
1100: The nurse starts a new care plan for the resident in order to promote
the resident’s quality of sleep and rest time of 7 to 8 hours daily. The nurse
recommends in the care plan to increase the resident’s daytime activity,
change his pants daily, limit his nap time, and take him to the outdoor
activity 3 times a week for 1-hour period. The nurse further instructs the
resident to consume caffeine with breakfast only. The nurse notes new
orders from the primary health care provider to change furosemide time to 9
am and 5 pm, zolpidem 5 mg by mouth at bedtime as needed for sleep, and
lorazepam 1 mg i.m. once daily for anxiety. After 3 days of following the
new care plan, the resident starts sleeping for 7 hours, eating all his meals,
and having a daily bowel movement.
the intervention is indicated, nonessential, or contraindicated for the
resident at this time.
STEP 5
care facility.
Nurse’s
Notes
meals.
1100: The nurse starts a new care plan for the resident in order to promote
the resident’s quality of sleep and rest time of 7 to 8 hours daily. The nurse
recommends in the care plan to increase the resident’s daytime activity,
change his pants daily, limit his nap time, and take him to the outdoor
activity 3 times a week for 1-hour period. The nurse further instructs the
resident to consume caffeine with breakfast only. The nurse notes new
orders from the primary health care provider to change furosemide time to 9
am and 5 pm, zolpidem 5 mg by mouth at bedtime as needed for sleep, and
lorazepam 1 mg i.m. once daily for anxiety. After 3 days of following the
new care plan, the resident starts sleeping for 7 hours, eating all his meals,
and having a daily bowel movement.
Identify the primary health care provider’s order and nursing intervention
that the nurse should implement immediately from among the primary
health care provider’s plan of care.
□ Intervention 1: Increase outdoor activity

□ Intervention 2: Change furosemide time as ordered
□ Intervention 3: Administer lorazepam
□ Intervention 4: Limit caffeine consumption
□ Intervention 5: Increase resident’s daytime activities
□ Intervention 6: Limit client napping
STEP 6
care facility.
Nurse’s
Notes
meals.
1115: Orders
Order 1 Lorazepam 1 mg i.m. once daily for anxiety
Order 2 Change furosemide time to 9 am and 5 pm
Order 3 Zolpidem 5 mg by mouth at bedtime as needed for sleep
The nurse has performed the interventions as ordered by the health care
provider and included in the plan of care. Select the assessment finding that
best indicates the primary goal for the treatment plan was achieved.
□ Finding 1: The resident starts eating 80% of his meals.

□ Finding 2: The resident starts sleeping for 7 hours per night.
□ Finding 3: The resident starts having a daily bowel movement.
□ Finding 4: The resident reports waking up once a night to urinate.
□ Finding 5: The resident reports, “My legs aren’t jerking as much.”
□ Finding 6: The resident has not displayed any verbal or physical
combativeness.
Chapter 13: Comfort and Pain
Management
STEP 1
A 60-year-old female client presents to the Urgent Care Center reporting
abdominal pain.
Nurse’s
Notes
1100: The client is grimacing, crying, moaning, clutching her fists tightly in
pain, and shifting her position as she sits in the waiting room. When the
nurse asks where the pain is located, the client points to the upper right
portion of her abdomen, describing the pain as deep, clamping, pressing,
and aching. The nurse examines the client’s abdomen for any discoloration,
swelling, and trigger point. As the nurse palpates the upper right portion of
the client’s abdomen, the nurse notes the sensitivity to touch and restricted
movement to the upper right portion of her abdomen, and the client quickly
pushes the nurse’s hand away. The nurse notes no discoloration to the upper
abdomen but observes that the site is swollen, with tenderness upon
palpation.
before and has not taken any medication for the pain. The only medication
the client currently takes is atorvastatin (Lipitor) 40 mg by mouth at night
for her high cholesterol level.

STEP 2
abdominal pain.
Nurse’s
Notes
palpation.
is consistent with the characteristics and effects of a specific type of pain.
Each finding may support more than one characteristic and effect of pain.
STEP 3
abdominal pain.
Nurse’s
Notes
palpation.
list.
The client is at highest risk for developing (list 1) as evidenced by the
client’s (list 2)
STEP 4
abdominal pain.
Nurse’s
Notes
palpation.
1200: The nurse notes the new order on the client’s electronic medical
record (EMR) for acetaminophen 325 mg 2 tabs by month every 6 hours as
needed for pain, for morphine sulfate 4 mg IV every 4 hours for pain, and to
place client on a clear liquid diet. The nurse develops a pain management
plan with the client that entails reducing client’s pain from 8 to 2 within 2
hours of pain management, client to sleep at least 6 hours without any
disturbance, client to bathe and dress herself without any constriction from
pain throughout hospital stay. An hour after taking the acetaminophen, the
client indicates that right upper abdominal pain has decreased from 8 out of
10 to 2 out of 10. Client indicates that she is still having a problem bathing
and dressing herself and is starting to have heartburn. The client also
refuses to get out of bed or eat. Client used bedpan and had a good bowel
movement.
each potential nursing intervention or nursing goal, check the appropriate
box to indicate if the intervention is indicated, nonessential, or
contraindicated for the client.
STEP 5
abdominal pain.
Nurse’s
Notes
palpation.
movement.
The nurse has received orders from the health care provider. Identify the
order that the nurse should perform immediately.
□ Order 1: Acetaminophen 325 mg 2 tabs by month every 6 hours as

needed for pain
□ Order 2: Morphine sulfate 4 mg I V every 4 hours for pain
□ Order 3: Clear liquid diet
□ Order 4: Atorvastatin 40 mg daily oral
□ Order 5: Activity as tolerated
□ Order 6: Schedule abdominal ultrasound
STEP 6
abdominal pain.
Nurse’s
Notes
palpation.
movement.
1215: Orders
Order 1 Acetaminophen 325 mg 2 tabs by month every 6 hours as
needed for pain
Order 2 Morphine sulfate 4 mg IV every 4 hours for pain
Order 3 Clear liquid diet
Order 4 Atorvastatin 40 mg daily oral
Order 5 Activity as tolerated
Order 6 Schedule abdominal ultrasound
The nurse has provided education to the client regarding all of the primary
health care provider’s orders. Select the client statements that indicate and
understanding of her plan of care. (Select all that apply.)
□ Finding 1: “I can get a pill for pain every 6 hours.”
□ Finding 2: “I’m still getting my cholesterol pill here in the hospital.”
□ Finding 3: “Staying in bed has really helped my stomach pain.”
□ Finding 4: “I’m sure if I could eat something solid I’d feel better.”
□ Finding 5: “The test will help determine if my gallbladder is the
problem.”
□ Finding 6: “The clear liquids will help my kidneys work correctly.”
Chapter 14: Safety
STEP 1
The primary nurse in the rehabilitation unit is providing a discharge report
to a home health nurse regarding a 74-year-old male client who is being
discharged home with his wife.
Nurse’s
Notes
1100: The primary nurse reports that the client was admitted 14 days ago to
the rehabilitation unit from the orthopedic unit for strengthening related to
status after a right hip open reduction internal fixation (ORIF). The client
was found on the bathroom floor at home by his wife, who said she did not
realize he had fallen. He was brought to the emergency room by the
emergency medical services. The client indicated that he got dizzy and fell.
His wife said he took his blood pressure medication too many times
because he did not remember taking it. Blood pressure on arrival to the
emergency room was 60/40, and pulse was 58. He was given 500 mL of
normal saline intravenously in the emergency room.
pneumonia. He has a history of high blood pressure and early-stage
antibiotics for the treatment of his UTI and pneumonia. Last night, he had a
productive cough of yellow material, and he sustained a skin tear to his left
arm when he was trying to remove the bilateral wrist restraint (which was
applied because he was pulling his IV line out). The restraint was
discontinued. The discharge order is for home health nurse visits 4 times a
week for management of medications (metoprolol 50 mg twice a day and
donepezil 5 mg daily at bedtime) and physical therapy 3 times a week for
restoration of ambulation. Vital signs are BP 140/94 with metoprolol 40 mg
given by mouth 30 minutes ago, pulse 74, respiration 20, and temperature
98.6°F oral.
Identify the top 4 client findings that would require immediate follow-up.
STEP 2
Nurse’s
Notes
status after a right hip open reduction internal fixation. The client was found
on the bathroom floor at home by his wife, who said she did not realize he
had fallen. He was brought to the emergency room by the emergency
medical services. The client indicated that he got dizzy and fell. His wife
said he took his blood pressure medication too many times because he did
not remember taking it. Blood pressure on arrival to the emergency room
was 60/40, and pulse was 58. He was given 500 mL of normal saline
intravenously in the emergency room.
98.6°F oral.
For each finding below, place a check mark in the appropriate box to
indicate if the finding is consistent with the characteristics of each of the
client’s safety issues. Each finding may support more than one safety issue.
STEP 3
Nurse’s
Notes
98.6°F oral.
list.
The diagnosis of (list 1) has increased the client’s risk for poor
compliance with medication therapy as evidenced by (list 2) .
STEP 4
Nurse’s
Notes
98.6°F oral.
1000: Two days post client’s discharge the home health nurse visits the
client at his home and finds the client sitting in a dark, smoky room in his
wheelchair with a waist restraint applied. The wheelchair is unlocked on a
tiled floor; the client is wearing a white shirt, a pair of blue pants, and
sneakers; and the room temperature is 90°F. The fire alarm is ringing,
because the client’s wife says she forgot she had steak in the oven, and it
burned. Client denies having any cough or pain. Vital signs are BP 110/70
mm Hg, pulse 74 beats/min, respiration 16 breaths/min, and temperature
97.6°F oral. The client and his wife indicate that client has not fallen since
he was discharged home. The wife indicates that “caring for him has
become overwhelming since he’s become so aggressive and even more
forgetful.”
The home health nurse reviews the home visit note entry made 2 days after
the client’s discharge. For each potential client/wife intervention, check the
appropriate box to indicate if the intervention is indicated, nonessential, or
contraindicated for the client.
STEP 5
Nurse’s
Notes
98.6°F oral.
forgetful.”
What nursing actions are appropriate at this time to provide for the client’s
immediate safety? (Select all that apply.)
□ 1. Move the client to a well-lighted, cooler, well-ventilated area of the

home.
□ 2. Assess the client’s surgical site.
□ 3. Instruct the client’s wife on the importance of locking the wheelchair
when it’s stationary.
□ 4. Discuss restraint alternatives with the client’s wife.
□ 5. Suggest that the client be moved to a long-term care facility for
Alzheimer’s clients.
□ 6. Assess the client’s ability to change his own shirt and put on pants.
□ 7. Talk with the client’s wife about her feelings of being overwhelmed.
STEP 6
Nurse’s
Notes
98.6°F oral.
forgetful.”
Based on the information currently available, highlight the findings that

suggest an improvement and/or stabilization of the client’s condition as
expected.
STEP 1
A 65-year-old male client was brought to the emergency room by his son
due to nose bleeding and bright red blood noted in his stool early this
morning.
Nurse’s
Notes
meals for over 3 weeks now. He indicates that he read in an article that
these herbs prevent coronavirus. Assessment and interview findings: The
client has a history of hypertension and atrial fibrillation. Home
medications are the following daily by mouth: Coumadin 5 mg, aspirin 325
mg, and enalapril 5 mg. Upon assessment, the client’s breath sounds are
clear bilaterally, skin pale and clammy to touch, and 2+ pulse irregular.
Vital signs: temperature 98.6°F oral, pulse 98 beats/min, respiration 18
breaths/min, BP 98/60, pulse oximetry reading 94% on oxygen at 2 L/min
via nasal cannula. Capillary refill is greater than 3 seconds. The client is
alert and oriented to person, place, and time. The client’s son states, “Dad
often retakes his meds because he does not remember taking them.” Client
says, “I like taking herbal supplements.”

STEP 2
morning.
Nurse’s
Notes
is consistent with the characteristics. Each finding may support more than
one characteristic and effect of safe medication use.
STEP 3
morning.
Nurse’s
Notes
list.
client’s (list 2) .
STEP 4
morning.
Nurse’s
Notes
1100: Client is admitted to medical accompanied by son.

Orders: 500 mL 0.9% normal saline bolus
Schedule endoscopy for am.
1200: The client’s son calls the nurse because the bedside vital sign monitor
alarm is beeping, and his father says he does not feel good. The client is
alert but appears weak, with pale, diaphoretic skin, and his nose is bleeding,
with clots noted. After asking the son to wait in the lounge area, the nurse
pinches all the soft parts of the client’s nose shut using the thumb and index
finger for 2 minutes, and applies an ice pack to the bridge of the client’s
nose. Vital signs: temperature 98.6°F oral, pulse 120 beats/min, respiratory
rate 28 breaths/min, blood pressure 86/58 mm Hg, pulse oximetry reading
94% on oxygen at 2 L/min via nasal cannula. The nurse increases the
oxygen to 3 L/min via nasal cannula and starts 500 mL 0.9% normal saline
intravenous bolus as ordered. Client’s nose stops bleeding 15 minutes after
the application of the ice pack. Nursing interventions include placing client
on a cardiac monitor, washing client’s face, and making client NPO for GI
testing in am Current vital signs: temperature 98.6°F oral, pulse 110
beats/min, respiratory rate 20 breaths/min, blood pressure 98/64 mm Hg,
and pulse oximetry reading 98% on oxygen at 2 L/min via nasal cannula.
the intervention is indicated, nonessential, or contraindicated for the client.
STEP 5
morning.
Nurse’s
Notes

Based on client needs, use a check mark to indicate the order in which the
following actions should be implemented
STEP 6
morning.
Nurse’s
Notes

1300: The client is currently resting quietly, with son at bedside. Current
vital signs: temperature 98.6°F oral, pulse 88 beats/min, respiratory rate 16
breaths/min, blood pressure 104/68 mm Hg, and pulse oximetry reading
98% on oxygen at 3 L/min via nasal cannula. Capillary refill greater than 3
seconds. No observable signs of epistaxis. IV bolus administration
completed. Skin dry and pink. Client is oriented to person, place, and time.
Highlight documentation statements that indicate that the client’s condition

has shown improvement.
STEP 1
Mr. Tomlin has recently moved to this area and is seeking to affiliate with a
senior care clinic. Today he is having his initial history and physical
assessment.
Nurse’s
Notes
1200: Mr. Tomlin is a 69-year-old who lives alone since the death of his
wife 2 years ago. He moved to the area to be closer to 2 of his 3 adult
children. A son and a daughter live within 20 miles of his home, while a
daughter is currently living in Spain. He retired 6 years ago from the daily
operations of a small metal plating business he owned and operated for 38
years.
needing to; I seem to usually have a stuffy nose. Client states, “I’m in pretty
good shape, but I get tired more easily than before I retired. But I still play
9 holes of golf twice weekly with friends.”
The client is currently prescribed lisinopril 2.5 mg (PO) daily for
hypertension and timolol 0.25% 1 drop in each eye daily. The client weighs
168 lb and is 5′11″ tall.
Assessment findings:
Diagnostic laboratory results: White blood cells (WBC) 4,500/μL, red

blood cells, (RBC) 4.2 million cells/μL, hemoglobin (Hgb) 13.8 g/dL,
hematocrit (Hct) 43%
Temperature 96.6°F (35.9°C)
Respiratory system: Respiratory rate 16 breaths/min. A mild nasal
septal deviation is noted. Client presents with a slightly barreled chest.
Client states smoking “a few cigarettes a day since I was in my 20s.”
Cardiovascular system: Heart rate 80 beats/min, regular; blood
pressure 110/76 mm Hg. Several varicose veins noted in lower
extremities bilaterally.
associated with either bladder or kidney infection. Client reports slight
difficulty starting urine flow, particularly in the morning, and getting
up once or twice during the night to urinate. Client reports slight urine
leakage.
Integumentary system: Three healed scars noted on knees (bilaterally)
and one on forearm. Client reports all were experienced “years ago
while working.” Several seborrheic keratosis noted on back and neck.
Gastrointestinal system: No remarkable results noted upon assessment.
Client reports occasional constipation managed with a fiber-based
laxative.
bilaterally.
Highlight the assessment and history findings generally associated with

age-related changes observed in older adults.
Mr. Tomlin is a 69-year-old who lives alone since the death of his wife 2
years ago. He moved to the area to be closer to 2 of his 3 adult children. A
son and a daughter live within 20 miles of his home, while a daughter is
currently living in Spain. He retired 6 years ago from the daily operations of
a small metal plating business he owned and operated for 38 years. Client
reports: “I need to clear my throat a lot more than I remember needing to; I
seem to usually have a stuffy nose. Client states, “I’m in pretty good shape,
but I get tired more easily than before I retired. But I still play 9 holes of
golf twice weekly with friends.” The client is currently prescribed lisinopril
2.5 mg (PO) daily for hypertension and timolol 0.25% 1 drop in each eye
daily. The client weighs 168 lb and is 5′11″ tall.
difficulty star ting urine flow, particularly in the morning, and getting
leakage.
Client reports occasional constipation managed with a fiberbased
laxative.
bilaterally.
STEP 2
assessment.
Nurse’s
Notes
years.

leakage.
laxative.
bilaterally.
Which assessment and history findings are possible triggers for respiratory-
related health issues for this client? (Select all that apply.)
□ 1. Timolol 0.25% 1 drop in each eye daily

□ 2. The need to clear throat often
□ 3. RR: 16 breaths/min
□ 4. WBC: 4,500/μL
□ 5. T: 96.6°F (35.9°C)
□ 6. Cigarette habit
□ 7. Barrel chest
STEP 3
assessment.
Nurse’s
Notes
years.
Diagnostic Laboratory results: White blood cells (WBC) 4,500/μL, red

leakage.
laxative.
bilaterally.
list.
The nurse recognizes that the client is at highest risk for developing (list
1) as evidenced by the client’s (list 2) and supported by (list 3) .
STEP 4
assessment.
Nurse’s
Notes
years.

leakage.
laxative.
bilaterally.
1230: The nurse begins plans to address the respiratory risk factors the
client has demonstrated as well as to implement specific interventions.
What actions would the nurse include in the client’s plan of care at this
time? (Select all that apply.)
□ 1. Strategies for boosting WBC count
□ 2. Educating the client on the risks of heavy metal contact
□ 3. Strategies to best ensure effective smoking cessation efforts
□ 4. Instructions on how best to keep upper respiratory passages patent
□ 5. Educating the client on the effects of deep breathing exercises on
respiratory function
□ 6. Educating the client about recognizing the signs and symptoms of
respiratory infections
□ 7. Strategies for the conservation of energy to best facilitate effective
STEP 5
assessment.
Nurse’s
Notes
years.

leakage.
laxative.
bilaterally.
Complete the following sentence by choosing from the list of options.

The nurse would first (list 1) to (list 2) .
STEP 6
assessment.
Nurse’s
Notes
years.

leakage.
laxative.
bilaterally.
1400: One month later at a follow-up appointment, the client and nurse
discuss the client’s efforts at smoking cessation.
The nurse evaluates the effectiveness of previous health-related teaching.

Use a check mark to indicate which client action listed in the left column
indicates greatest effectiveness of the nursing actions taken.
STEP 1
The home health nurse is visiting Mr. Hatfield, a 78-year-old who recently
fractured his ankle. Mr. Hatfield is now recuperating in the apartment he
shares with his wife of 52 years.
Nurse’s
Notes
1100: The nurse notices that the client’s wife appears pale and weary, and
the apartment appears untidier than it has been during previous visits. When
the nurse asks Mrs. Hatfield if she has any concerns about the health of
either her husband or herself, she simply replies, “Oh, I’m just really tired.
There is a lot to keep up with now that Keith is laid up with this broken
ankle.” Mr. Hatfield adds, “She won’t complain, but I know she is really,
really tired and she been getting dizzy quite a bit lately.” It is then that Mrs.
Hatfield volunteers that she has had a few episodes she describes as “my
heart sort of flutters, but it doesn’t last too long.”
Highlight the information presented in the scenario that requires follow-up

by the nurse.
STEP 2
Nurse’s
Notes
1110: The nurse asks Mrs. Hatfield for permission to conduct a focal
cardiac assessment. She agrees, and the nurse begins the assessment.
Assessment findings heart rate 80 beats/min, regular; blood pressure 110/76
mm Hg; respiratory rate 16 breaths/min; pulse oximetry 94%; history: age:
74; smokes “just a couple” cigarettes daily; diagnosed with hypertension 6
years ago and is being treated with lisinopril 2.5 mg (PO) daily and a low-
fat, low-sodium diet; diagnosed with iron deficiency anemia 2 years ago
and is being treated with ferrous sulfate 150 mg/daily and diet.
Choose the most likely options for the information missing from the
statement below by selecting from the list of options provided.
The nurse recognizes that based on observation, and the client’s
assessment and history data, she is currently at risk for cardiac
complications, especially (list 1) , (list 1) , and (list 1)
STEP 3
Nurse’s
Notes
statements below by selecting from the lists of options provided.
Based on the client’s current risk factors, the client’s priority need will
be to prevent (list 1) . In addition, she will need interventions to prevent
other related potentially life-threatening complications, especially (list 2)
and (list 2) .
STEP 4
Nurse’s
Notes
Use a check mark to indicate which actions listed in the left column would
be included in the plan of care at this time.
STEP 5
Nurse’s
Notes
1400: Five days later, Mrs. Hatfield is seen by her primary care provider
(PCP), and a cardiology consult is ordered. As a result of diagnostic testing,
a diagnosis of atrial fibrillation is confirmed. A consult with a registered
nutritionist is ordered, resulting in a weight reduction plan with a 20-lb
weight loss target. The following interventions are prescribed: rivaroxaban
10 mg daily, discontinue lisinopril 2.5 mg daily, verapamil (immediate
release) 40 mg t.i.d. (3 times a day).
The home health nurse is now visiting both Mr. and Mrs. Hatfield.
During this initial visit with Mrs. Hatfield, the nurse is reviewing the
current medical record and planning care interventions.
Complete the following sentences by choosing from the list of options.

STEP 6
Nurse’s
Notes
1400: Five days later, Mrs. Hatfield is seen by her primary care provider
(PCP), and a cardiology consult is ordered. As a result of diagnostic testing,
a diagnosis of atrial fibrillation is confirmed. A consult with a registered
nutritionist is ordered, resulting in a weight reduction plan with a 20-lb
weight loss target. The following interventions are prescribed: rivaroxaban
10 mg daily, discontinue lisinopril 2.5 mg daily, verapamil (immediate
release) 40 mg t.i.d. (3 times a day).
The home health nurse is now visiting both Mr. and Mrs. Hatfield.
During this initial visit with Mrs. Hatfield, the nurse is reviewing the
current medical record and planning care interventions.
Two weeks later: Visiting home health nurse visits
The nurse is evaluating the effectiveness of Mrs. Hatfield’s plan of care.

Which of the following client actions or statements indicate effectiveness?
(Select all that apply.)
□ 1. “My heart hasn’t fluttered in more than a week.”

□ 2. Client is wearing a nicotine patch on upper left arm.
□ 3. The client is observed getting up from her chair slowly.
□ 4. “It’s been too cold to walk outside lately, but I’ll start again when it’s
warmer.”
□ 5. “It’s really difficult eating all the vegetables I’m supposed to have each
day.”
□ 6. “Now that Keith can get around more easily, things have been easier to
cope with.”
□ 7. “We put our pills into these divided plastic containers; it has helped me
remember to take them.”
Chapter 18: Digestion and Bowel
Elimination
STEP 1
The nurse is completing a direct admission assessment of an 80-year-old
female client on a telemetry unit.
Nurse’s
Notes
from her primary health care provider’s office. The client states that she
lasted for 3 days. She further indicates that the pain became unbearable and
sharp in nature, so she called her son and asked him to drive her to her
doctor’s office. During the office visit, she becomes diaphoretic, starts to
vomit, and begins to experience chest pain. The client reports being
otherwise healthy except for occasional heartburn spells that started 6
months ago.
Her primary health care provider quickly decides to admit her to the
follows: place on telemetry, protoxin 20 mg IV daily, and Tylenol 650 mg
suppository every 6 hours as needed for pain. Labs ordered include cardiac
enzymes STAT and CBC (complete metabolic profile). Keep client NPO for
stress test in the morning. Home medications include calcium 2,000 mg/d
and antacids over the counter. Client indicates that she takes the antacids
frequently for her heartburn and doubles the dose of her calcium
consumption because of occasional joint pain.
1500: The nurse notes that the client’s abdomen is distended and difficult to
palpate. Client indicates that she doesn’t remember the last time she had a
bowel movement but thinks it was sometime last week. Client reports
burning stomach pain and belching with frequent hiccups. Vital signs:
temperature 99.0°F oral, pulse 120, respirations 20, blood pressure 120/76,
bedside blood glucose level 70 mg/dL, and pulse oximetry 99% on room
air. The client’s weight is 97 lb. She indicates that she has lost 15 lb within
the last month; she has been eating less because it hurts to chew. The nurse
notes that the client’s teeth have various degrees of erosion, abrasions of
crown and root structure, and high prevalence of tooth loss. Client indicates
that she does not like drinking water but drinks a nutritional shake that her
primary health care provider ordered because of her weight loss. Client is
tentatively diagnosed with possible myocardial infarction, gastroesophageal
reflux disease (GERD), peptic ulcer disease (PUD), and gastritis.

STEP 2
Nurse's Notes
months ago.
is consistent with myocardial infarction (MI), constipation, or
gastroesophageal reflux disease (GERD). Each finding may support more
than one problem.
STEP 3
Nurse's Notes
months ago.
list.
client’s (list 2).
STEP 4
Nurse's Notes
months ago.
1600: The nurse documents that all client’s lab results are within
therapeutic levels, but the client continues to have abdominal pain, now
with projectile vomiting. Prescriptions noted for ondansetron 4 mg IV every
6 hours, pantoprazole 40 mg daily (PO), milk of magnesia 30 mL PO as
needed every 8 hours for constipation, saline laxative (rectal), and a KUB
(kidney, ureters, bladder) x-ray: STAT. Myocardial infarction ruled out.
The nurse has reviewed the Nurses’ Notes entries from 1300 through 1600.
For each potential nursing intervention, check the appropriate box to
indicate if the intervention is indicated, nonessential, or contraindicated for
the client.
STEP 5
Nurse's Notes
months ago.
The nurse has received prescriptions from the primary health care provider
and has begun to prioritize implementation.
Complete the following sentences by choosing from the lists of options.
The nurse will first administer (list 1) in order to (list 2)
STEP 6
Nurse's Notes
months ago.
1600: Orders
Milk of magnesia
Ondansetron KUB
Saline laxative
The nurse has performed the interventions as ordered by the primary health
care provider. Select the assessment findings that indicate that the client’s
condition has improved.
Assessment finding
□ Finding 1: Client’s vomiting stops.
□ Finding 2: Client’s abdominal pain is relieved.
□ Finding 3: Client has a large bowel movement 3 times.
□ Finding 4: Client denies having any chest pain.
□ Finding 5: Client continues to have heartburn.
□ Finding 6: Client skin warm and dry to touch.
STEP 1
Two days ago, a 55-year-old female was admitted to the intensive care unit
(ICU) with a diagnosis of hyperglycemia based on a serum glucose level of
320 mg/dL. Today she is being transferred to a medical–surgical unit.
Nurse’s
Notes
vital signs: temperature 99.6°F oral (37.5°C), heart rate 84, respiratory rate
18, blood pressure 112/72, pulse oximetry 99% room air, bedside glucose
level 105 mg/dL. Client is alert to place, person, and time. The nurse’s notes
from admission indicate that the client has a history of type 2 diabetes
without any comorbidities.
1445: While using the restroom, the client calls out for the nurse. The nurse
finds the client in tears and holding her lower back. She reports a severe
burning pain when she voided. The nurse notes that the client’s urine color
is dark brown, cloudy with a distinctive smell. The client indicates that
although she still has a strong urge to urinate, she cannot now void. The
nurse places a call to the physician on call.

STEP 2
Nurse’s
Notes
is consistent with the characteristics of the suggested condition. Each
finding may support more than one characteristic and effects of pain.
STEP 3
Nurse’s
Notes
list.
The client is at highest risk for developing (list 1) as best evidenced by
the client’s (list 2).
STEP 4
Nurse’s
Notes
1600: Orders
STAT urinalysis (UA)

Monitor vital signs every 2 hours
IV 0.9% normal saline at 100 mL/hour
Sugar-free protein drink supplement twice a day
Cranberry juice with every meal
Acetaminophen 325 mg by mouth every 6 hours as needed for pain
and fever
Vitamin C 75 mg daily oral
Levofloxacin 250 mg I V daily for 3 days
For each potential nursing intervention, check the appropriate box to

indicate if the intervention is indicated, nonessential, or questioned.
STEP 5
Nurse’s
Notes
1600: Orders

and fever

STEP 6
Nurse’s
Notes
1600: Orders

and fever
1800: Urine UA result indicates bacteriuria greater than 120 CFU/mL
and urine culture pending. Upon completion of the first dose of the
levofloxacin and acetaminophen, the client verbalized relief of her
back pain. Vital signs: temperature 98.8°F oral (37.1°C), pulse 78,
respiratory rate 20, blood pressure 120/76, pulse oximetry reading 99%
on room air. Bedside glucose level 120 mg/dL.
Highlight the findings that specifically indicate the client’s UTI treatment is
effective.
Chapter 20: Reproductive System
Health
STEP 1
system at a local seniors’ community center.
Nurse’s
Notes
1300: Mrs. French, age 65, is attending the discussion and shares with the
nurse that she has a solid lump on her left inner breast and that her left
nipple is painful and has a dark brown discharge. She adds that her nipples
are retracted, and the surrounding nipple skin is thickened. She further
indicates that although she only sleeps 6 hours a night, her appetite is good.
She says to the nurse, “No one in my family has had breast cancer, so I’m
sure this isn’t serious.” The nurse suggests that she should see her primary
care provider (PCP) to discuss her signs and symptoms.
Mr. Harding, age 72, is in the same meeting and asks the nurse, “Do
you think that I should make an appointment to go see my PCP?” The nurse
asks him if he would like to discuss his concerns privately. He responds, “I
don’t know what is wrong with me. I’m not as interested in sex as I used to
be, and when I am in the mood, I have a problem starting and keeping an
erection.” He adds, “For the past month, I have been having urinary
problems. I’m up frequently at night needing to urinate; my stream is hard
to start, but then stops and starts again when I think that I am finished. My
bladder never completely empties, causing me to dribble urine throughout
the day.” When the nurse asks if he has any chronic health issues, he shares,
“I have diabetes, hypertension, and high cholesterol.” He then adds, “I
never drink any alcohol nor abuse drugs, and I stopped smoking 30 years
ago. I work out every day, and I have maintained an ideal weight.” The
nurse agrees that Mr. Harding should follow up with his PCP.
Identify the top 3 concerns mentioned by Mrs. French that would require
follow-up by her PCP.
STEP 2
Nurse’s
Notes
is consistent with the characteristics of Mr. Harding’s condition. Each
finding may support more than one characteristic and effects of pain.
STEP 3
Nurse’s
Notes
list.
Mrs. French’s highest risk is for a diagnosis of (list 1) as evidenced by
her report of (list 2)
STEP 4
Nurse’s
Notes
1400: After the meeting, Mrs. French calls to schedule an appointment with
her PCP in 7 days. Mr. Harding immediately drives himself to his PCP’s
office and is able to schedule an appointment for the next day.
Next afternoon: Mr. Harding is examined by his PCP. After the appropriate
diagnosis procedures, it is determined that he is likely experiencing benign
prostatic hyperplasia (BPH). He is to be examined by a urologist in 24
hours.
24 hours later: After the urological consult, Mr. Harding is diagnosed with
BPH. He is prescribed tamsulosin 0.4 mg orally daily. A follow-up
appointment and lab work is scheduled in 4 months.
be included in the plan of care.
STEP 5
Nurse’s
Notes
Next afternoon: Mr. Harding is examined by his PCP. After the

appropriate diagnosis procedures, it is determined that he is likely
experiencing benign prostatic hyperplasia (BPH). He is to be examined by a
urologist in 24 hours.
7 days after community session: Mrs. French goes to her PCP

appointment. After a breast examination, a mammogram is scheduled for
the next day.
The nurse would reinforce for Mrs. French that the purpose of the
mammogram is to (list 1) in order to primarily (list 2) .
STEP 6
Nurse’s
Notes
Next afternoon: Mr. Harding is examined by his PCP. After the appropriate
diagnosis procedures, it is determined that he is likely experiencing benign
prostatic hyperplasia (BPH). He is to be examined by a urologist in 24
hours.
7 days after community session: Mrs. French goes to her PCP

appointment. After a breast examination, a mammogram is scheduled for
the next day.
Highlight the findings that indicate that both Mrs. French and Mr. Harding
are receiving appropriate care.
STEP 1
retired and lives with his wife.
Nurse’s
Notes
1400: Since retiring 6 years ago from his job as a construction foreman, the
74-year-old has become progressively more inactive, in part as a result of
several medical diagnoses. The client demonstrates moderate difficulty
getting out of his chair and walking to the table where his wife is sitting.
His wife, who is of the same age and considerably more active, urges him to
exercise more, but Mr. Radford responds that he worked hard all his life and
now that he is retired, he deserves to “sit in my chair and take it easy if I
want to.” His wife is unhappy because they do not participate in activities
together. She states, “Ed frequently falls asleep in his chair while doing
what he does most of the time—watching television.” Mr. Radford
acknowledges that he “has difficulty walking more than from here to the
corner, and steps make me winded.”
Highlight the assessment findings that require immediate follow-up by the

nurse.
STEP 2
Nurse’s
Notes
1420: Mr. Radford’s medical history includes benign prostatic hypertrophy

(BPH), osteoarthritis (OA), gout, cataracts, and diverticulosis as well as
psoriasis. He is allergic to strawberries and a variety of seasonal plants.
Although he self-medicates his seasonal allergies and avoids strawberries,
he is currently being treated for these diagnoses by his primary health care
provider (PCP).
Which situations identified by his medical history may be placing Mr.

Radford at risk for mobility issues? (Select all that apply.)
□ 1. OA
□ 2. Gout
□ 3. BPH
□ 4. Psoriasis
□ 5. Cataracts
□ 6. Diverticulosis
□ 7. Strawberry allergy
STEP 3
Nurse’s
Notes

provider (PCP).
Based on the client’s statements and history data, the client’s priority
need will be to (list 1) to prevent potentially life-threatening complications
of immobility, especially (list 2) and (list 2) .
STEP 4
Nurse’s
Notes
provider (PCP).
1430: The nurse and Mr. Radford discuss the need for him to consider
adopting a regular exercise program what will address his needs to improve
his endurance, flexibility, and strength.
Indicate with a check mark the exercise-related actions listed below that are
focused on the areas of concern for the client at this time. Only one
selection can be made for each action.
STEP 5
Nurse’s
Notes

provider (PCP).
1445: Mr. Radford has reached some decisions about the components of an
exercise program that would meet his physical needs while appealing to
him sufficiently to help ensure his ongoing adherence.

STEP 6
Nurse’s
Notes

provider (PCP).
1445: Mr. Radford has reached some decisions about the components of an
exercise program that would meet his physical needs while appealing to
him sufficiently to help ensure his ongoing adherence.
1 month later: The visiting home health nurse pays a follow-up visit to Mr.
Radford. The client volunteers, “We’ve been taking a ¼ mile walk each day,
usually after dinner.” When asked about osteoarthritis pain, Mr. Radford
states, “My knees still hurt, but I have to admit, the walking seems to help.”
His wife shares that “he still watches too much television, but he is really
good about getting in a walk every day.” The client shares that he plans to
gradually extend the walks to ½ mile within 3 weeks; he also mentions that
he attended his first yoga class last week. He claims he feels a little silly
doing the various yoga poses but knows it will help if he keeps at it.
Highlight the findings that indicate the client is progressing as expected.

STEP 1
A 65-year-old male client presents to the emergency department (ED),
reporting a sudden generalized numbness, weakness of his face, right arm,
and legs that started with mild pain 24 hours ago and has worsened.
Nurse’s
Notes
swallowing clear water. Pupils are unequal, slightly edematous, round, and
sluggishly reactive to light accommodation on his right pupil as compared
to his left pupil. The client has a history of Parkinson’s disease,
hypertension (HTN), diabetes, hyperlipidemia, and atrial fibrillation. The
client smokes 1 pack of cigarettes a day and has smoked for 50 years. He
denies drinking alcohol or use of street drugs. His daughter indicates that
the client had similar issues 6 months ago when he reported weakness;
numbness of the right side of his face, his right arm, and his right leg; and
slurred speech that lasted for a day but was not as severe as this. The
client’s vital signs are temperature 98.6°F oral (37.5°C), pulse 82,
respiratory rate 20, and blood pressure 190/110.

STEP 2
Nurse’s
Notes
is consistent with the characteristics of client’s condition. Each finding may
support more than one characteristic and effects of pain.
STEP 3
Nurse’s
Notes
list.
client’s (list 2)
STEP 4
Nurse’s
Notes
1300: Client seen by emergency department physician. Nurse notes new

orders from the physician:
Orders
Labetalol IV 20 mg over 1 to 2 minutes; may repeat once if BP

remains greater than 185/110 mm Hg
Magnetic resonance imaging (MRI) head STAT
Heparin drip per neuro protocol
Neuro checks every 15 minutes
1430: When the client returns from the radiology department an hour
later, his vital signs are temperature 98.6°F oral (37.0°C), pulse 80,
respiratory rate 24, and blood pressure 140/90. Client remains alert and
oriented to person, place, and time. He denies having any pain. The
nurse applies a cool compress to client’s forehead.
The nurse has reviewed the Nurses’ Notes entries from 0800 to 1300. For
each potential nurse intervention, check the appropriate box to indicate if
the intervention is indicated, nonessential, or questioned for the client.
STEP 5
Nurse’s
Notes

Orders

Complete the following sentence by selecting the correct option from the
list.
The client’s response to treatment is best identified by (list 1) .
STEP 6
Nurse’s
Notes

Orders

Highlight the assessment findings that indicate that the client’s condition
has improved.
STEP 1
The nurse is assessing a 75-year-old male client who presents at the primary
care clinic with reports of blurred vision.
Nurse’s
Notes
1000: The client indicates that he has been having clouded, blurred vision
“for quite some time now.” He reports more sensitivity to light, double
vision in his right eye, seeing “halos” around lights, and increasing
difficulty with vision at night. The nurse notes halos and glare on the field
of the client’s right’s eye. The client has a history of hearing impairment,
diabetes, benign prostatic hypertrophy (BPH), and hypertension. He is
prescribed tamsulosin 0.4 mg and lisinopril 5 mg daily. The client self-
medicates with aspirin (81 mg tablet) daily. His body mass index (BMI) is
35%; he has smoked 2 packs of cigarettes a day for over 30 years. His skin
is dry, warm, and intact upon skin assessment. The primary care provider
referred the client to an ophthalmologist. The client’s vital signs are
temperature 98.6°F oral (37.5°C), pulse 74, respiratory rate 22, and blood
pressure 132/90.

STEP 2
Nurse’s
Notes
pressure 132/90.
is consistent with the common characteristics of the client’s condition. Each
finding may support more than one characteristic and effects of the client’s
condition.
STEP 3
Nurse’s
Notes
pressure 132/90.
list.
client’s (list 2) and (list 2) .
STEP 4
Nurse’s
Notes
pressure 132/90.
Day of ophthalmologist consult: After examining the client, the

ophthalmologist recommends cataract surgery to the right eye, and the
client agrees. The surgery is scheduled for 5 days in the future. The nurse
provides pre-op instructions.
Which actions would the nurse include in the plan of care at this time?
(Select all that apply.)
□ 1. Eating restrictions
□ 2. Adjustments to existing medication therapies
□ 3. Administration of preoperative medications
□ 4. Transportation requirement on the day of surgery
□ 5. Need to schedule postsurgical follow-up for 48 to 72 hours postsurgery
STEP 5
Nurse’s
Notes
pressure 132/90.

Day of surgery: Postoperatively the nurse notes the following orders:
Orders
Fluoroquinolone drops, 2 drops to right eye q.i.d. for 2 weeks

Steroid eye drops, 2 drops to right eye q.i.d. for 2 weeks
Apply right eye patch
Provide discharge instructions
Complete the following sentence by choosing from the lists of options.

STEP 6
Nurse’s
Notes
pressure 132/90.

Day of surgery: Postoperatively the nurse notes the following orders:

Orders
Fluoroquinolone drops, 2 drops to right eye q.i.d. for 2 weeks

Steroid eye drops, 2 drops to right eye q.i.d. for 2 weeks
Apply right eye patch
Provide discharge instructions
At follow-up postoperative appointment: Client arrives with right
eye patched for the appointment. He is wearing his hearing aid and is
accompanied by his adult son. When asked, the client indicates that his
right eye “itches a little, but nothing I can’t handle.” The client denies
any surgically related pain and volunteers that “I haven’t lifted
anything heavier than a cup of coffee.” When the patch is temporarily
removed, the client indicates his vision “is much clearer than before.”
A follow-up appointment is made for 2 weeks.
Highlight the findings that indicate the client is compliant and is

progressing as expected.
STEP 1
Mr. Angelo, a 75-year-old widower who lives alone, is visiting the primary
care center for his regular 6-month checkup.
Nurse’s
Notes
to have an elevated blood glucose level and has signs of dehydration. When
asked about symptoms, he admits that he has “felt sluggish lately.”
When questioned, Mr. Angelo confirms that he is taking his medication
as prescribed; however, when he shows the nurse his prescription bottle, the
nurse notices that it contains a substantial amount of the 90-day supply of
medications that was obtained over 4 months ago. When questioned about
his diet, the client seems evasive, commenting, “I’ve never been a great
cook, but I get by.”
Highlight the assessment finding that is of immediate concern for the nurse.
STEP 2
Nurse’s
Notes
1110: Assessment and history confirms that Mr. Angelo is 5′7″ tall and
weighs 290 lb, and at the time of his diabetes diagnosis he was counseled
and educated on the need to reduce weight, to follow good dietary practices,
and to be adherent to his medication therapy. It’s noted that Mr. Angelo is
found to have gained 4 lb since his last checkup. His last hemoglobin A1c
was 8.6%. When questioned, he admits to not following his dietary plan;
instead he says he prefers eating the heavy pastas, fried foods, and cakes
that he grew up on and loves. The client adds, “I know diabetes increases
my risk for all kinds of health issues, but after all, at my age good eating is
one of the few pleasures I have left.”
The nurse recognizes that based on the client’s medical history and
assessment data, he is currently at risk for complications, related especially
to the function of the (list 1) , (list 1) , (list 1) , and (list 1) systems.
STEP 3
Nurse’s
Notes
Based on the client’s condition and assessment data, the client’s priority
need will be to prevent (list 1) . In addition, he will need interventions to
prevent other chronic complications, especially (list 1) and (list 1) .
STEP 4
Nurse’s
Notes
1120: The nurse reinforces the need for adherence to medication and diet
therapies. Mr. Angelo agrees that he needs to take more control over his
diabetes. He and the nurse discuss what changes are necessary to best adjust
his plan of care and what actions he should take to bring about these
changes.
Use a check mark to indicate which outcomes listed in the left column
would be newly included in Mr. Angelo’s plan of care to best meet his
current needs.
STEP 5
Nurse’s
Notes
changes.
be implemented by Mr. Angelo to achieve the outcomes found in his plan of
care.
STEP 6
Nurse’s
Notes
changes.
Two months later at a scheduled checkup: Mr. Angelo presents at the
checkup with his adult son and shares that he has decided to move in with
his son’s family. He will have his own “granddad apartment above the
garage.” He says he is looking forward to having regular contact with
family and that although he will be responsible for most of his own meal
preparation, it will be nice to have Sunday dinner with the family. His latest
hemoglobin A1c was 6.4%, and his weight is currently 270 lb.
Arrangements are being made to send his medical records to the primary
health care provider, who will be managing his care after his move in 2
weeks.
Highlight the finding that best indicates the client is achieving expected
outcomes.
STEP 1
Nurse’s
Notes
home with a past medical history significant for lung cancer with metastasis
to the bone. Upon admission it is noted that the client is incontinent for both
urine and stool. An external male catheter is in place. Admission
assessment confirmed a stage II sacral pressure injury (PI) measuring 3 ×
1.5 × 0.1 cm, 0% epithelial tissue, and mild incontinence-associated
dermatitis (IAD). Mr. Baldwin’s Braden score is 13. The client’s weakened,
fragile state keeps him bedridden except for occasional transfer to a chair.
The patient’s pain is assessed on a scale of 0 to 10, with 0 being the absence
of pain and 10 being severe pain. The patient reports significant pain in his
back, reports pain levels of 8 to 9 with repositioning, and consistently
requests p.r.n. pain medication. Mr. Baldwin’s vital signs are heart rate 70
beats/min, respiratory rate 20 breaths/min, temperature 37.5°C (99.6°F),
blood pressure 100/64 mm Hg, and pulse oximetry 93% room air.
Prealbumin: 13
Albumin: 2.8
White blood cells (WBC): 12,000/μL
Highlight the assessment findings that require immediate follow-up by the

nurse.
STEP 2
Nurse’s
Notes
Prealbumin: 13
Albumin: 2.8
The nurse recognizes that based on the assessment findings, the client is
currently at greatest risk for acute complications, especially related to (list
1) , (list 1) , (list 1) , and (list 1) .
STEP 3
Nurse’s
Notes
Prealbumin: 13
Albumin: 2.8
Based on the client’s condition and assessment findings, the client’s
acute priority need will be to (list 1) . In addition, he will need interventions
to prevent potentially life-threatening complications of infection, especially
(list 2) , (list 2) , and (list 2) .
STEP 4
Nurse’s
Notes
Prealbumin: 13
Albumin: 2.8
1430: The critical care nurse is creating the client’s plan of care
including treatment goals and interventions to best affect the client’s
wound healing capacity.
What short-term goals will the nurse include in the plan of care to help
achieve the client’s primary nutritional goal within 4 weeks? (Select all that
apply.)
□ 1. Client’s surgical wound will be assessed as being in the maturation

phase of healing.
□ 2. Client will be able to effectively consume diet to achieve desired
prealbumin level goal.
□ 3. Client will demonstrate a weight gain of between 4 and 6 lb.
□ 4. Client’s albumin level will be within normal range.
□ 5. Client’s BUN level will be within normal range.
□ 6. Client’s BMI will be within normal range.
□ 7. Client’s WBC will be within normal range.
STEP 5
Nurse’s
Notes
Prealbumin: 13
Albumin: 2.8
1430: The critical care nurse is creating the client’s plan of care including
treatment goals and interventions to best affect the client’s wound healing
capacity.
1500: Mr. Baldwin’s primary care provider writes the following

prescriptions:
Darvocet PO b.i.d. p.r.n.

Morphine I V q8h p.r.n.
Ciprofloxacin 1 g I V over 60 minutes q8h
Turn and reposition q2h
Wound care consultation
Nutritional consultation
Insert Foley catheter and attach to urinary drainage system
be implemented to address the client’s need for effective wound healing.
STEP 6
Nurse’s
Notes
Prealbumin: 13
Albumin: 2.8
1430: The critical care nurse is creating the client’s plan of care including
treatment goals and interventions to best affect the client’s wound healing
capacity.
1500: Mr. Baldwin’s primary care provider writes the following

prescriptions:
Darvocet PO b.i.d. p.r.n.

Morphine I V q8h p.r.n.
Ciprofloxacin 1 g I V over 60 minutes q8h
Turn and reposition q2h
Wound care consultation
Nutritional consultation
Insert Foley catheter and attach to urinary drainage system
0900, 6 days post admission: Mr. Baldwin is being prepared for transfer to
the hospital’s long-term care unit for continued care. The client’s wound
presents with 70% epithelial tissue regenerated and resolution of IAD.
Client’s Foley catheter draining yellow, clear urine, 1,600 to 1,800 mL
daily. Client’s most recent vital signs are blood pressure 102/68 mm Hg,
heart rate 72 beats/min, respiratory rate (sinus rhythm) 18 breaths/min,
pulse oximetry 93% on room air, and temperature 97.6°F (36.4°C). His
body mass index (BMI) is 18. Client’s most recent diagnostic laboratory
results include
BUN of 7 mg/dL
Prealbumin of 16 mg/dL
Albumin of 4 g/dL
WBC are 8,500/μL

Chapter 26: Cancer
STEP 1
Susan Janes is a 65-year-old who is presenting at a women’s clinic for her
annual checkup.
Nurse’s
Notes
1200: Mrs. Janes’ medical history includes a ruptured appendix at age 6,
two vaginal deliveries, and being diagnosed as prediabetic 2 years ago. The
client states she has “smoked just a couple of cigarettes a day since I was
about 20.” The client denies drinking any alcohol, saying, “I don’t like the
taste of any of it.” Mrs. Janes worked outdoors at a local nursery for 20
years prior to retiring 8 months ago. She reports no incidence of cancer in
her immediate family, but several members of her extended family have
been diagnosed with various forms of cancer. Her assessment results
include body mass index (BMI) 25, blood pressure 114/72 mm Hg (on beta-
blocker), respiratory rate 16 breaths/min and regular, pulse oximetry 94%,
heart rate 76 beats/min and regular, and temperature 98.4°F (36.9°C) oral.
Highlight the client’s possible risk factors that require follow-up by the
nurse.
STEP 2
annual checkup.
Nurse’s
Notes
1210: When asked whether she has any concerns she would like to discuss,
Mrs. Janes responds, “Well, at my age I am concerned about cancer. Can we
talk about how I would know if there is something to worry about?”
When assessing the client, which questions should the nurse ask concerning
warning signs of cancer? (Select all that apply.)
□ 1. “Have you experienced any uterine bleeding since completing

menopause?”
□ 2. “Have you had any changes in your bowel habits lately?”
□ 3. “How long does it usually take for a cut to heal?”
□ 4. “Is indigestion or bloating a problem for you?”
□ 5. “When did you have your last mammogram?”
□ 6. “May I look at any warts or moles you have?”
□ 7. “Do you have any difficulty swallowing?”
□ 8. “Have you ever had a colonoscopy?”
STEP 3
annual checkup.
Nurse’s
Notes
1220: The discussion between the nurse and Mrs. Janes now focuses on
prevention strategies and interventions she can consider to minimize her
risk for developing cancer.
Use a check mark to indicate which potential actions listed in the left
column are a priority for cancer prevention in Mrs. Janes’ case.
STEP 4
annual checkup.
Nurse’s
Notes
be included in the plan of care.
STEP 5
annual checkup.
Nurse’s
Notes
1230: The client and nurse have decided upon the prevention plan to be
implemented. The nurse begins to educate and demonstrate specific actions
that focus on the client’s personal cancer prevention plan.

STEP 6
annual checkup.
Nurse’s
Notes
1230: The client and nurse have decided upon the prevention plan to be
implemented. The nurse begins to educate and demonstrate specific actions
that focus on the client’s personal cancer prevention plan.
Use a check mark to indicate which of the client statements listed in the left
column indicate effectiveness of the actions taken related to cancer
prevention and management.
Chapter 27: Mental Health
Disorders
STEP 1
department.
Nurse’s
Notes
hard to catch my breath.” The client’s spouse shares that “George has been
so worried about the coronavirus epidemic. He is so concerned about all of
us getting sick, especially his 84-year-old mother.” The client asks, “Am I
having a heart attack? I’m very afraid it could be the coronavirus.”

The emergency department nurse should identify (list 1) as the client’s
primary presenting problem followed by (list 2) based on (list 2) .
STEP 2
department.
Nurse’s
Notes
1220: Stat electrocardiogram (ECG) and stat troponin level ordered.
1245: Client’s current vitals are heart rate 110 beats/min apical, respirations
24 breaths/min, blood pressure 158/88 mm Hg, and temperature 99.2°F
(36.8°C). Client’s electrocardiogram and laboratory values are all within
normal limits. Client has history of prescription steroid use to treat eczema
flare-ups but denies any other chronic illnesses, stating, “I eat well and
exercise regularly.” Client is pacing and is easily startled but follows
directions fairly well with redirection. Client frequently repeats, “Even if it
isn’t a heart attack, something bad is going to happen.” Client continues to
report palpations and dyspnea as well as mild nausea but denies having
chills, muscle aches, headache, or a cough. Client shows great hesitation
about discussing his previously verbalized concern about being infected
with the COVID-19 virus. When asked, the client states, “I’m not afraid;
it’s my mother who is so scared of dying from it.” Client’s spouse shares,
“Although George is a social drinker, he’s been drinking much more than
usual this last month.”
Use a check mark to indicate which assessment finding is Supportive or

Inconclusive of a potential mental health diagnosis. All assessment findings
should be used and can be used only once.
STEP 3
department.
Nurse’s
Notes
usual this past month.”
The nurse suspects that the client is attempting to manage his anxiety with
the use of common coping mechanisms. Which findings support this
suspicion? (Select all that apply.)
□ 1. States, “I’m not afraid; it’s my mother who is so scared of dying from
it”
□ 2. Now shows hesitation verbalizing concerns related to COVID-19
□ 3. Increase in typical alcohol consumption
□ 4. Heart rate 110 beats/min
□ 5. History of eczema
□ 6. Hyperpnea
STEP 4
department.
Nurse’s
Notes
What assessment question will help the nurse identify a possible factor
contributing to the client’s potential for experiencing a panic attack? (Select
all that apply.)
□ 1. “Are you currently treating your eczema?”

□ 2. “Do you use any recreational drugs?”
□ 3. “Do you consider yourself a religious individual?”
□ 4. “How much coffee, tea, and soda do you consume on an average day?”
□ 5. “Are you experiencing any problems getting 6 to 8 hours of sleep
nightly?”
□ 6. “Are you currently experiencing any problems with bowel
elimination?”
□ 7. “Do you have an established relationship with a primary health care
provider?”
□ 8. “Would you describe your alcohol drinking habits over the last several
weeks?”
STEP 5
department.
Nurse’s
Notes
1430: Client discharged to home with:
An appointment scheduled for 1300 next day at outpatient clinic

Prescription for meprobamate to begin immediately
1315, next day: (Note provided by clinic nurse interviewing client the day
after emergency department visit) Client is accompanied by spouse. Reports
taking meprobamate as prescribed but adds, “I was watching TV about
midnight when for no reason I started trembling, and I felt my heart
palpitating again. I couldn’t tell you what I was afraid of, but I was sure
something bad was happening.” Client’s spouse describes the client as
being diaphoretic and having a panicked look on his face. Both client and
spouse agree that the episode lasted about 10 minutes, with the client
adding, “Then I began to calm down.”
What intervention should the nurse introduce to the client’s plan of care to
help minimize and control the recurrence of panic attacks? (Select all that
apply.)
□ 1. Teach relaxation techniques.

□ 2. Discuss benefits of meditation.
□ 3. Teach controlled breathing exercises.
□ 4. Discuss the options of medication therapy.
□ 5. Encourage to begin slowly limiting caffeine consumption.
□ 6. Identify three ways to engage in appropriate regular exercise.
□ 7. Discuss effective support strategies available to the client’s spouse.
STEP 6
department.
Nurse’s
Notes
1430: Client discharged to home with:
An appointment scheduled for 1300 next day at outpatient clinic

Prescription for meprobamate to begin immediately
1315, next day: (Note provided by clinic nurse interviewing client the
day after emergency department visit) Client is accompanied by
spouse. Reports taking meprobamate as prescribed but adds, “I was
watching TV about midnight when for no reason I started trembling,
and I felt my heart palpitating again. I couldn’t tell you what I was
afraid of, but I was sure something bad was happening.” Client’s
spouse describes the client as being diaphoretic and having a panicked
look on his face. Both client and spouse agree that the episode lasted
about 10 minutes, with the client adding, “Then I began to calm
down.”
1415, follow-up visit: (Note provided by clinic nurse interviewing the

client at a follow-up visit 14 days after emergency department visit) Client’s
current vitals are heart rate 80 beats/min apical, respirations 12 breaths/min;
blood pressure 122/78 mm Hg, and temperature 97.8°F (36.5°C). Client is
accompanied by spouse. Client claims to have experienced two panic
attacks in the last 6 days. The events lasted approximately 10 to 15 minutes,
with varying degrees of severity. The client volunteered that he
implemented both controlled breathing and relaxation techniques to help
manage the anxiety during the events. Client claims to be medication
adherent, adding, “I can tell the medication is helping. I’m even sleeping
better than I have in months.” When asked about lifestyle changes he has
implemented to help manage his anxiety, the client states, “It’s hard to
exercise; I’ll see about joining a gym.” The client’s spouse shares, “He has
cut back on his alcohol, but he still drinks more coffee than he should, and
he’s started smoking again. I’m out of ways to get him to comply.” Client
mentions his seasonal allergies are becoming a problem and volunteers he is
taking an over-the-counter decongestant, which seems to be helping.
Another follow-up appointment is made for 7 days later, and client
demonstrates an understanding of the value of calling the clinic hotline if he
needs to in the meantime.
The nurse has reviewed the history note provided by the clinic nurse
assessing the client at a follow-up visit 14 days after client’s initial
emergency department visit. Highlight the data that require reinforcement
and/or an adaptation of the client’s plan of care to help achieve goals related
to anxiety management and panic attack prevention.
Chapter 28: Delirium and
Dementia
STEP 1
A home health nurse is making an initial home visit to evaluate 69-year-old
Mr. Downey and to assist his spouse in developing effective caregiving
plans.
Nurse’s
Notes
1400: Mr. Downey was diagnosed with Alzheimer’s disease several months
ago. The client has since retired, and Mr. Alvera, the client’s spouse,
identified no specific problems until this past month, when he repeatedly
called the primary health care provider to discuss the new symptoms
exhibited by his husband. These included urinary incontinence, eating
difficulties, and Mr. Downey’s tendency to wander away from their home
both during the day and at night.
Highlight the client’s assessment findings that require immediate follow-up

by the nurse.
STEP 2
plans.
Nurse’s
Notes
1415: The nurse notes that these new problems appear to have devastated
Mr. Alvera; he looks fatigued and claims to be eating and sleeping poorly.
He has expressed a sense of confusion and lack of understanding related to
his spouse’s diagnosis while firmly stating that “I will never consider
placing my husband in an institution” and that he’ll “take care of him at
home even if it kills me.”
Use a check mark to indicate which assessment finding is associated with

each of the listed potential problems. Note that some assessment findings
may not be used, and some may be used more than once.
STEP 3
plans.
Nurse’s
Notes
Based on the client’s assessment findings and Mr. Alvera’s interview
statements, the priority need for Mr. Alvera will be to prevent the
development of (list 1) . In addition, Mr. Alvera will need interventions to
prevent additional stress, especially related to (list 2) and (list 2) .
STEP 4
plans.
Nurse’s
Notes
Which goals would the nurse include in Mr. Downey’s plan of care to best
address the needs of Mr. Alvera? (Select all that apply.)
□ 1. Client will remain free from injury.

□ 2. Care will be provided in a consistent manner.
□ 3. An establish toileting routine will be instituted.
□ 4. Weight will be maintained within the ideal range.
□ 5. Client will sleep 5 to 7 hours nightly, with one daytime nap.
□ 6. Client will be enrolled in a local adult day care program.
□ 7. Alzheimer’s Disease and Related Disorders Association will be utilized
as a resource.
STEP 5
plans.
Nurse’s
Notes
1430: The nurse encourages Mr. Alvera to share his feelings, frustrations,
and concerns about his role as caregiver to his husband. The nurse and Mr.
Alvera identify several issues that Mr. Alvera agrees are priorities, and they
discuss how to address those issues as they occur.

In order to best address Mr. Alvera’s identified needs, the nurse would
first (list 1) to (list 2) .
STEP 6
plans.
Nurse’s
Notes
1600: (2 weeks later at a follow-up appointment) The nurse notes that Mr.
Downey appears calm and cooperative, although detached from the
conversation. Mr. Alvera confirms that his husband has been eating better
and has even regained 1 lb since the last visit. He is also sleeping at least 6
hours a night, which allows Mr. Alvera to rest uninterrupted most nights.
The Alzheimer’s Disease and Related Disorders Association representative
suggested applying safety locks to the outside doors; these have helped
prevent Mr. Downey from wondering outdoors and have provided Mr.
Alvera with “much peace of mind.” Mr. Downey has been attending an
adult day care program two afternoons a week. The experience created
some disruption in their daily routine originally, but Mr. Alvera feels they
are settling into the new routine well. He shares that he uses the time alone
to read, engage in some gardening, or to visit with friends. When asked
about long-term care for his husband, Mr. Alvera responds, “It isn’t
necessary yet, but I’ll be open to the possibility in the future, if needed.”
Highlight the findings that indicate that Mr. Alvera’s stress level has been
diminished, as expected.
Chapter 29: Living in Harmony
With Chronic Conditions
STEP 1
year-old client who is part of an elder care program that provides bimonthly
home visits to clients with multiple medical diagnoses.
Nurse’s
Notes
pulmonary disease (COPD), glaucoma, and macular degeneration. He self-
administers oral medications and eye drops for these conditions. The client
has a son who lives in another state and a daughter who visits weekly to
assist with shopping and chores. He has daily telephone and Internet contact
with several friends and both of his children.
about the lapse in his prescription refill, he responds, “I’ll have my daughter
take me to the pharmacy when she isn’t so busy.” When discussing his next
appointment with his primary care provider (PCP), Mr. Petrovich states that
he “will get around to making an appointment.”
Petrovich spends most of the day watching television because he lacks the
energy to do much else. The nurse notices that the clothing he is wearing is
soiled and that he needs a shave and haircut. He has an odor, indicating he
hasn't adequately bathed for a while.
Highlight the assessment findings that suggest the client is in need of
follow-up by the nurse.
STEP 2
Nurse’s
Notes
hasn’t adequately bathed for a while.
The nurse recognizes that based on the client’s list of chronic conditions
and assessment findings, he is currently at risk for complications, especially
(list 1) , (list 1) , and (list 1) .
STEP 3
Nurse’s
Notes
Use a check mark to indicate which potential problems listed in the left
column are a priority for prevention.
STEP 4
Nurse’s
Notes
Use a check mark to indicate which goals listed in the left column would be
included in the plan of care to meet current health and wellness concerns.
STEP 5
Nurse’s
Notes
1345: The nurse shares with Mr. Petrovich identified during the visit, and
they discuss how his health, wellness, and quality of life are being affected
by these factors.
Complete the following sentence by choosing from the list of options.

To best address the client’s identified needs, the nurse would first (list
1) to (list 2) .
STEP 6
Nurse’s
Notes
1345: The nurse shares with Mr. Petrovich identified during the visit, and
they discuss how his health, wellness, and quality of life are being affected
by these factors.
1500 (2 weeks later): The home health nurse is visiting Mr. Petrovich for
the second time and makes the following observations. The client is sitting
on the porch in anticipation of the visit. He offers the nurse some iced tea
and a cookie that his home health aide left for him. He is well groomed and
shares that his daughter took him for a haircut last week just before he went
to his PCP appointment. He volunteers that a friend will be coming over to
visit later, and they intend to take a walk “around the block.” The client
volunteers that having his medication refills delivered to him at home is “a
lot easier, and I don’t have to bother anyone to take me to the pharmacy.”
He and the nurse discuss the possibility of contacting the library to see
about getting his favorite mystery books in a more readable format.

Appendix B Answers to Next
Generation NCLEX-Style
Questions
Chapter 11: Nutrition and
Hydration
STEP 1
Finding 6 is an immediate concern because eating frozen meals could

potentially increase weight gain and increase high blood pressure as a result
of the increased amount of sodium used to preserve the meal. This could
create harm to the client because she has a family history of high blood
pressure and obesity.
Findings 3 and 1 are of next immediate concern because smoking is a
vasoconstriction that increases the risk for multiple disease processes. A
follow-up of the BP is important because the client’s systolic BP of 140 is
high, considering her family history. Normal BP is 120/80.
Finding 4 is the next most important finding to address because an infected
tooth could lead to a systemic infection. This is not the most immediate
concern because the client does not currently have a tooth infection. Older
persons need to be advised of the importance of toothbrushing and regular
visits to the dentist to preserve their teeth. Nurses should make sure older
patients in all care settings receive adequate oral hygiene.
STEP 2
Findings 1, 2, 3, 4, and 5 are consistent with high risk of high blood
pressure. Finding 1, smoking, is a vasoconstrictor that contracts the blood
vessels, causing them to narrow, resulting in impaired blood circulation.
Finding 2, high BMI, indicates obesity (finding 5), which also causes a
vasoconstriction effect that could cause impaired cardiac output. Regarding
finding 3, frozen foods are high in sodium, which could cause high blood
pressure.
NCSBN Clinical Judgment Measurement Model:
Analyze Cues
STEP 3
The factors contributing to the client’s diagnosis of hypertension include a
BMI of 35.9%, her smoking habit, and her alcohol consumption.
Obesity contributes to vascular resistance, which increases the risk of
hypertension and heart failure. Nicotine is a vasoconstrictor that narrows
and hardens artery walls, resulting in hypertension. Consuming red wine
may have a positive effect on heart health, but the client’s volume of daily
wine is above the recommended amount, thus contributing to weight gain
and heart disease. Eating a single meal each day doesn’t contribute to
hypertension but may result in weight loss; however, this is not a healthy
strategy for achieving weight loss.

Prioritize Hypotheses
STEP 4
Based on the client’s new order, the nurse would immediately implement
intervention 2; the nurse would schedule a registered dietitian consult for
the client to facilitate weight loss management. This nutritional specialist
will customize and map out a therapeutic diet consumption for the client.
After completion of intervention 2, the nurse would implement
interventions 1 and 5 and schedule intervention 4 before the client leaves.
Intervention 1 is related to fostering the client’s awareness of eating habits
and amount and types of food ingested while intervention 5 is a strategy
designed to consume calories and promote general wellness. Intervention 4
is essential so that lab results can be compared from the previous visit and
so that interventions can be evaluated. Intervention 3 (increase her social
outings) does not address immediate change in client’s condition but could
help if the client later develops depression, which is a complication that
sometimes accompanies obesity.
Generate Solutions
STEP 5
After receiving orders from the health care provider, the nurse should have
given priority to implementing making appointment for a registered
dietitian consult and then scheduling client to return in 2 weeks for a
follow-up to best ensure client success with achieving desired outcomes.
The nurse’s priority should be to make the dietary consult appointment in
order to best provide the client with the information and strategies to
achieve the treatment goal of weight loss. The nurse would then schedule
the 2 weeks follow-up appointment. This follow-up is essential so that lab
results can be compared from the previous visit and so that interventions
can be evaluated. All other options are important but depend in part of the
reinforcement of the consult and evaluation of treatment goal achievement
and need for plan adjustment.

Take Actions
STEP 6
☑ 1. BP: 130/76
☑ 2. Weight: 243 lb
□ 3. Fasting glucose fingerstick: 80 mg/dL
☑ 4. Client states, “I’ve started wearing a nicotine patch.”
☑ 5. Respirations: 12
□ 6. Client states, “I walk sometimes, but I really don’t enjoy it.”
☑ 7. Client reports eating a fresh salad for lunch most days.
The decrease in BP, respirations, and weight are indications of improved
physical health. The introduction of a nicotine patch demonstrates a positive
change in attitude about treatment interventions. Eating a salad
demonstrates adherence to weight loss strategies that is also a positive
indication of adherence to the treatment plan. The client’s comment
regarding walking is not as positive and represents resistance to the plan of
care. The client’s fasting glucose levels, originally and now, are within
normal limits, so this does not indicate either a positive or negative change
in health status.

Evaluate Outcomes
STEP 1
Findings 1, 2, 3, and 4 are of immediate concern because they represent

significant and potentially harmful deviations from normal values (i.e.,
sleep and rest impairment).
Demonstrations of verbal combativeness and frustration can be related to a
variety of possible causes and so should be assessed further.
STEP 2
Findings 1 and 3 are consistent with phase advance.

Findings 2 and 4 are consistent with sleep latency.
Finding 5 is consistent with nocturnal myoclonus.

Analyze Cues
STEP 3
The resident’s general health will be most negatively impacted by his risk
for developing insomnia as evidenced by the resident’s reporting 2 hours of
sleep nightly.
The resident’s greatest risk to his general health is that of a sleep deficiency
associated with insomnia resulting in only 2 hours of sleep a night.
Although both restless legs syndrome and nocturnal myoclonus, as well as
the characteristic involuntary leg muscle movement, can affect sleep, their
impact is not as fundamental to the resident’s general health. Anxiety may
result in frustration and combativeness but more likely are panic and
physical signs like tachycardia and tachypnea.

STEP 4
Based on the resident’s new order, the nurse would immediately implement
intervention 1. After completion of intervention 6, the nurse would
implement intervention 4 and intervention 3. Intervention 5 is not essential
to the care plan goal of promoting rest and sleep time. Intervention 2 is
contraindicated for the resident’s care plan goal.

Generate Solutions
STEP 5
□ Intervention 1: Increase outdoor activity.
☑ Intervention 2: Change furosemide time as ordered.
□ Intervention 3: Administer lorazepam.
☑ Intervention 4: Limit caffeine consumption.
□ Intervention 5: Increase resident’s daytime activities.
☑ Intervention 6: Limit client napping.
The nurse would immediately change the resident’s plan of care by

changing of administration time for furosemide (2), which will decrease the
need to urinate during the night, thus promoting the resident’s rest and sleep
time; limiting the client’s caffeine intake to minimize the stimulant effect
(4); and limit the client’s napping to encourage sleeping at night (6).
Implementation of these interventions will assure the major triggers for
insomnia are minimized first. Although the implementation of the
interventions related to the resident’s activities will likely have a positive
impact on sleep, they are likely to take additional time to bring about a
change in the sleep pattern. Lorazepam should not be implemented because
the lorazepam given daily to the elderly could cause confusion, and the
resident’s anxiety could be from the lack of adequate rest and sleep time.
Take Actions
STEP 6
The nurse has performed the interventions as ordered by the health care
provider and included in the plan of care. Select the assessment finding that
best indicates the primary goal for the treatment plan was achieved.
□ Finding 1: The resident starts eating 80% his meals.

☑ Finding 2: The resident starts sleeping for 7 hours per night.
□ Finding 3: The resident starts having a daily bowel movement.
☑ Finding 4: The resident reports waking up once a night to urinate
□ Finding 5: The resident reports, “My legs aren’t jerking as much.”
□ Finding 6: The resident has not displayed any verbal or physical
combativeness.
Success of the treatment plan is evidenced by the resident sleeping 7 hours

per night and waking up once a night to urinate. Both findings indicate
more uninterrupted sleep which was the goal. While the remaining options
are all possible improvements, none are directly involved with the goal of
improved rest and sleep. The decrease in involuntary leg movement is an
improvement, but the total elimination of such movement is the goal.
Chapter 13: Comfort and Pain
Management
STEP 1
Findings 1, 2, 4, and 5 are of immediate concern because they represent

significant and potentially harmful deviations from normal values
consistent with cholelithiasis (gallstones).
Finding 3 would also require follow-up, but not as urgently. Because the
client has never had this kind of pain before, further testing must be done.
This finding could be associated with advanced disease process, which can
present with an acute pain.
Finding 6 is a hypercholesterolemia medication that has no effect on the
pain; however, the nurse would follow up with the lab work (liver and
kidney function test) to check toxicity of the medication later because it
presents less potential for harm than findings 1, 2, 4, and 5 and is less time
sensitive than finding 3.
STEP 2
Interventions 1, 3, and 4 are consistent with acute pain; they are consistent
with cholelithiasis (gallstones).
Intervention 2 is consistent with visceral pain, which is a pain that is
associated with nociceptors of the thoracic, pelvic, or abdominal viscera
(organs).
Intervention 5 is consistent with chronic pain that is not associated with
cholelithiasis (gallstones).
Analyze Cues
STEP 3
The client is at highest risk for developing cholelithiasis as evidenced by
the client’s right upper abdominal pain.
Assessment 1 is consistent with imminent development of disorder 1 and is
consistent with the other information provided by the client.
Assessments 2, 3, and 4 are too general to be definitively associated with
any of the disorders.

STEP 4
Based on the client’s new order, the nurse would immediately implement
intervention 3. After completion of intervention 3, the nurse would
implement interventions 1 and 4. Interventions 5 and 6 do not address
immediate change in condition, so they are nonurgent, but they are essential
for a later time. Intervention 2 is contraindicated for elderly patients
because narcotics such as morphine may worsen the client’s condition.

Generate Solutions
STEP 5
n Order 1: Acetaminophen 325 mg 2 tabs by month every 6 hours as
needed for pain
n Order 2: Morphine sulfate 4 mg IV every 4 hours for pain
n✔ Order 3: Clear liquid diet
n Order 4: Atorvastatin 40 mg daily oral
n Order 5: Activity as tolerated
n Order 6: Schedule abdominal ultrasound
The nurse would immediately implement order 3, which is meant to reduce

gastric peristalsis in order to prevent nausea and vomiting that would
increase in client’s pain. The nurse would then implement order 1, which is
meant to initiate management of the client’s pain. Order 2, morphine
sulfate, should be implemented if the acetaminophen is not effective. The
orders related to the remaining medication, activity, and diagnostic testing
can be implemented after the client’s pain has been addressed.

Take Actions
STEP 6
☑ Finding 1: “I can get a pill for pain every 6 hours.”

☑ Finding 2: “I’m still getting my cholesterol pill here in the hospital.”
□ Finding 3: “Staying in bed has really helped my stomach pain.”
□ Finding 4: “I’m sure if I could eat something solid, I’d feel better.”
☑ Finding 5: “The test will help determine if my gallbladder is the
problem.”
□ Finding 6: “The clear liquids will help my kidneys work correctly.”
The client demonstrates understanding of her plan of care when confirming

that she can have pain medication every 6 hours for pain and that she will
continue to receive her atorvastatin as previously prescribed. The client has
correctly identified the purpose of the order diagnostic test. The client’s
pain has decreased most likely because of effective pain management not
remaining in bed. It is not true that eating solid foods would help her feel
better, because it is important to minimize the work of the gastrointestinal
system until a diagnosis can be made. The clear liquids are an attempt to
provide fluids and nutrition, not to support kidney function.

Evaluate Outcomes
Chapter 14: Safety
STEP 1
Finding 1 is an immediate concern because uncontrolled level of high blood

pressure could lead to severe cardiovascular complications, such as stroke.
Finding 3 is an immediate concern because of potential respiratory
impairment; a productive cough of yellow material could be an indication
of fluid in the lung (lung infiltration), which could be a sign of reoccurring
pneumonia.
Findings 4 and 5 are of also of concern because the skin has been
compromised with an incision and abrasion that could result in an infection
if proper care is not provided.
STEP 2
Finding 1 Client forgetfulness is consistent with client’s diagnosis of

Alzheimer’s disease. Alzheimer’ disease is a form of dementia;
forgetfulness is a common characteristic of such cognitive disorders.
Findings 2 A BP of 140/94 is consistent with a diagnosis of hypertension.
As a general guide, hypertension is considered to be 140/90 or higher (or
150/90 or higher if you’re over the age of 80).
Findings 4 and 5 are consistent with the patient developing infection. A
right hip incision could lead to infection because the skin has been
compromised by the incision. Productive cough of yellow material could
indicate that his pneumonia infection is not properly resolved.

Analyze Cues
STEP 3
The diagnosis of Alzheimer’s disease has increased the client’s risk for poor
compliance with medication therapy as evidenced by impaired memory.
Disorder 1: Alzheimer’s disease, a form of dementia, is characterized by
cognitive deficiency as demonstrated by impaired memory (assessment 2).
The client’s wife explained that, “he took his blood pressure medication too
many times because he did not remember taking it” as the cause of his fall
that resulted in the fractured hip.
Disorder 2: Hypertension is not supported by any of the provided options.
Disorder 3: Pneumonia is not supported by any of the provided options.

STEP 4
Intervention 1, Client sitting in a dark, smoky room in his wheelchair
creates a high risk for a fall. Adequate lighting promotes good visibility and
aids in avoiding safety hazards.
Intervention 2, The wheelchair being unlocked on a tiled floor, poses a risk
for the client to fall. The wheelchair should have been locked.
Intervention 3, The client wearing a white shirt and blue pants is
nonessential because the condition and color of the patient’s clothing does
not have an effect on safety.
Intervention 4, Client is wearing sneakers, is indicated based on the client’s
unsteady gait; sturdy footwear is useful for helping to prevent falls.
Intervention 5, The client’s room temperature of 108°F (43°C) is
contraindicated based on the client’s condition because he could develop
hyperthermia, which could lead to brain damage.

Generate Solutions
STEP 5
☑ 1. Move the client to a well-lighted, cooler, well-ventilated area of the

home.
☑ 2. Assess the client’s surgical site.
☑ 3. Instruct the client’s wife on the importance of locking the wheelchair
when it’s stationary.
☑ 4. Discuss restraint alternatives with the client’s wife.
□ 5. Suggest that the client be moved to a long-term care facility for
Alzheimer clients.
□ 6. Assess the client’s ability to change his own shirt and put on pants.
☑ 7. Talk with the client’s wife about her feelings of being overwhelmed.
The client’s immediate surroundings present an unhealthy environment, and

the client should be removed to a cooler, better-ventilated area immediately.
The client is a risk for injury if the surgical site has become infected. The
wife should be engaged in a discussion concerning wheelchair safety as
well as alternatives to restraint use, because both can result in client injury.
The nurse needs to assess the wife’s physical and emotional states in order
to best plan for appropriate interventions to assure the safety of both client
and spouse. The assessment of the client’s ability to dress himself is not an
immediate concern and is not directly associated with his safety. It is
premature to suggest the client’s institutionalization; the discussion with the
client’s wife and collaboration with this interdisciplinary health care team
must occur in order to arrive at possible interventions.

Take Actions
STEP 6
The client’s denial of any cough or pain suggests improvement of his
condition. All of his vital signs are within normal limits, which indicates an
improvement of BP management and no signs of possible infection. The
lack of falls since discharge indicates a diminished risk of injury for the
client.
Evaluate Outcomes
STEP 1
Finding 3, which indicates the client is actively bleeding, is of immediate

concern. If this bleeding, as evidenced by nose bleeding and bright red
blood in stool, is not stopped, the client could experience severe
complications such as hypovolemic shock, hypoxia, and other
cardiovascular problems.
Finding 5 is the next immediate concern to follow up on; a low level of
circulatory blood that is enriched with hemoglobin could lead to an
ischemia because of impairment in tissue perfusion.
Finding 1 and 4 are the next concerns; when the bleeding is stopped, and
intravenous fluid is given, the BP and the heart rate will return to a
therapeutic level. Elevated pulse is a sign of compensatory effect of the
heart working harder to maintain hemostasis.
STEP 2
Findings 1 and 4 are consistent with unsafe medication use that could
contribute to a client’s bleeding because these herbs serve as blood thinners,
and the client is already taking aspirin and coumadin that also have a blood-
thinning property. Using garlic, turmeric, cayenne pepper, and cinnamon
when also taking aspirin and coumadin creates an unsafe medication use
that could lead to a hypovolemic shock and could cause other serious
cardiovascular complications.
Findings 2, 3, and 5 could lead to hypovolemic shock as a result of
excessive loss of blood from the nose and GI bleeding. If not properly
managed, low BP and low pulse oximetry could lead to hypovolemic shock,
and irregular heartbeat could lead to atrial fibrillation. Low blood level or
loss of blood from the circulatory system could cause the organs not to
perfuse effectively, creating a low circulatory blood level.

Analyze Cues
STEP 3
The client is at highest risk for developing hypovolemic shock as evidenced
by the client’s BP of 98/60.
Assessment 1 is abnormal and is consistent with imminent development of
disorder 4 because presence of low blood pressure is one major
manifestation of hypovolemia.
Assessments 2 and 3 are normal and would not be contributing factors for
hypovolemic shock.
Assessment 4 (history of atrial fibrillation) would not contribute to risk for
hypovolemic shock but rather cardiogenic shock.

STEP 4
Intervention 2, the administration of 500 mL 0.9% normal saline (NS)
intravenous bolus as ordered, will bring the client’s BP to a therapeutic
level. Intervention 3, placing the client on a cardiac monitor, will allow the
providers to monitor the client’s cardiac activities, which is important
because the client has a history of AFIB. Intervention 4, keeping the client
NPO for possible GI testing in am, is important because an endoscopy to
detect the bleeding site is likely. Intervention 5, pinching all the soft parts of
client’s nose shut using the thumb and index finger for 2 minutes, will
promote coagulation. The nurse would follow this by applying an icepack
(or a bag of frozen peas or beans) to the bridge of the client’s nose to help
shrink blood vessels and reduce bleeding.
Intervention 1, administrating client’s enalapril 5 mg by month, is
contraindicated for the client’s low BP of 86/58. Enalapril is an angiotensin-
converting enzyme (ACE) inhibitors. It works by relaxing blood vessels so
blood can flow more easily. Enalapril is a drug that is used for treating high
blood pressure; if given to a client with low BP, it will lower the blood
pressure.
Intervention 6, asking the client’s son to leave the room, this is
contraindicated because the best evidence-based research indicates that
family members should be allowed to be involved in client’s care and
should be allowed to remain in the client’s room in crises unless the family
member is disrupting the care of the client.
Intervention 7, washing client’s face, is not essential because it doesn’t
directly apply to managing the client’s immediate health needs.

Generate Solutions
STEP 5
The nurse would immediately implement Action 3: increasing the oxygen
to 3 L/min via nasal cannula, to keep the client from desaturating. The nurse
would next perform Action 1: pinching all the soft parts of the client’s nose
shut using the thumb and index finger for 2 minutes would simulate a
coagulative effect that will stop the client’s nose bleeding. Action 2: starting
500 mL 0.9% normal saline (NS) intravenous bolus as ordered will help
bring the BP to a therapeutic level.

Take Actions
STEP 6
.
The client’s current pulse and respiratory rates and pulse oximetry reading
with supplemental oxygen are now within normal limits and BP is moving
higher; toward the normal range. Nose bleeding has stopped, and skin is no
longer diaphoretic or pale. Temperature and capillary refill are not directly
related to possible hypovolemic shock but rather infection and hypoxia,
respectively.

Evaluate Outcomes
STEP 1
The aging process brings about changes to all body systems because
changes occur in individual cells that make up the various organs. These
changes bring about changes in both function and appearance. These
changes are noted in Mr. Tomlin’s comments related to fatigue, bowel
elimination, and urination habits and function, peripheral vascular function,
and the presence of increased viscosity of mucus all resulting for the
alteration of metabolism, and changes in system functions. Aging affects
existing structures such as joints, nasal passages, visual function, and
dermatological regeneration. Although Mr. Tomlin’s diagnostic results are
within the low normal range, this is likely due to his body’s diminishing
ability to regenerate the various blood components.

Recognize Cues
STEP 2
□ 1. Timolol 0.25% 1 drop in each eye daily
☑ 2. The need to clear throat often
□ 3. RR: 16
□ 4. WBC: 4,500/μL
□ 5. T: 96.6°F (35.9°C)
☑ 6. Cigarette habit
☑ 7. Barreled chest
Reduced secretions from the submucosal gland cause the mucus in the
nasopharynx to be thicker and harder to expel; this also can cause a chronic
tickle in the throat and coughing. The accumulation of mucus in the air
passages can trigger both impaired respirations and infections. The loss of
skeletal muscle strength in the thorax and diaphragm, combined with the
loss of resilient force that holds the thorax in a slightly contracted position,
contributes to the observed barrel chest. This results in less air exchange
and more air and secretions remaining in the lungs, impairing gas exchange
and increasing risk of infection. Smoking has significant effects on the
respiratory system, including bronchoconstriction, early airway closure,
reduced ciliary action, inflammation of the mucosa, and increased mucous
secretions and coughing. Smoking triggers a variety of respiratory diseases
and complications. The client’s respiratory rate is within normal limits so is
not an indicator of respiratory distress. Mr. Tomlin’s WBC count is in the
low normal range, and his temperature, while low, is not abnormally low;
so, neither indicates a possible infection. Although timolol can cause
tightness of chest and irregular breathing, these are not common side
effects.

Analyze Cues
STEP 3
The nurse recognizes that the client is at highest risk for developing lung
cancer as evidenced by the client’s cigarette habit and supported by his
occupation.
The nurse recognizes that the client is at highest risk for developing lung
cancer as evidenced by the client’s cigarette habit. Smokers have twice the
incidence of lung cancer, a higher incidence of all respiratory diseases, and
more complications with respiratory problems, commonly suffering from
productive coughs, shortness of breath, and reduced breathing capacity. A
high incidence of lung cancer occurs among those who are chronically
exposed to agents such as chromates. Although obstructed upper respiratory
passages may result in an environment that supports an infection, the
client’s WBC count doesn’t indicate any infection. The client’s barrel chest
can impact gas exchange, but his respirations don’t indicate any existing
problem.

STEP 4
□ 1. Strategies for boosting WBC count
□ 2. Educating the client on the risks of heavy metal contact
☑ 3. Strategies to best ensure effective smoking cessation efforts
☑ 4. Instructions on how best to keep upper respiratory passages patent
☑ 5. Educating the client on the effects of deep breathing exercises on
☑ 6. Educating the client about recognizing the signs and symptoms of
respiratory infections
□ 7. Strategies for the conservation of energy to best facilitate effective
The client is at risk for respiratory infections, shortness of breath, and lung
cancer. Strategies to effect smoking cessation are critical to the respiratory
health of this client. Respiratory infections related to increased obstruction
associated with ineffective mucous removal would be positively impacted
by implementation of effective coughing and nose blowing. Early detection
and the resulting early treatment of respiratory infections are critical to the
respiratory health of this client. Deep breathing exercises will help ensure
optimum lung expansion, which will facilitate effective gas exchange that
has been impeded by the client’s barrel chest. Boosting WBC count is a
strategy that is required only when the body’s capacity to respond to an
infection is deficient. The client’s WBC count, although at the low end of
normal, seems to respond effectively when faced with an infection. The
time to educate the client about the risks of heavy metal contact was when
he was working with those substances. The client’s fatigue is not likely to
be solely a result of impaired respiratory function but rather a general
response to the aging process.

Generate Solutions
STEP 5
The nurse would first discuss the client’s feelings about engaging in a
smoking cessation program immediately to prevent any further risk of
developing lung cancer.
The priority focus is to prevent further risk of developing lung cancer by
ceasing to smoke. No signs or symptoms of lung cancer were identified
during the assessment or history taking process so confirming a diagnosis of
lung cancer is not the priority. Although being familiar with the signs and
symptoms of lung cancer are important for this client, because there is no
evidence of the current existence of lung cancer, the priority remains
stopping additional risk.
Take Action
STEP 6
The most effective evidence involves a demonstration of the client’s action

to stop smoking, such as use of a nicotine patch. (However, please note that
people over 65 have a greater risk of side effects from a nicotine patch.)
The client’s statement indicates a struggle, whereas the physical observation
indicates unobstructed upper airways.

Evaluate Outcomes
STEP 1
Atrial fibrillation (AF) is common in the elderly population. AF is the result

of age-related tissue changes affecting the atria (increase of size and fibrosis
development), resulting in lower and inferior electrical properties and
conduction that cause the atria to beat irregularly and in an uncoordinated
manner with the ventricles. Common signs and symptoms of AF include
palpitations (heart flutters), fatigue, and dizziness resulting from the altered
electrical conductivity of the heart.

Recognize Cues
STEP 2
The nurse recognizes that based on observation, and the client’s assessment
and history data, she is currently at risk for cardiac complications,
especially, thrombosis, cardiomyopathy, and heart failure.
The symptomology points to atrial fibrillation (AF) as the cause of Mrs.
Hatfield’s symptomology. AF causes ineffective myocardial stimulation,
resulting in a reduction in cardiac output when the demands on the heart are
increased and incomplete emptying of the cardiac chambers. These factors
places stress on the heart muscles, resulting in an enlarged heart muscle and
pooling of the blood, especially in the left atrium, and subsequent thrombi
formation. Aortic aneurysms are caused by “hardening of the arteries”
(atherosclerosis).

Analyze Cues
STEP 3
Based on the client’s current risk factors, the client’s priority need will be to
prevent clot formation. In addition, she will need interventions to prevent
other related potentially life-threatening complications, especially
hardening of the coronary arteries and hypertension.
Atrial fibrillation (AF) is an irregular and often rapid heart rate that occurs
when the two upper chambers of the heart experience chaotic electrical
signals. This dysfunction creates pooling of blood in the atriums, which
leads to clot formation. These clots have the potential to enter the blood
supply and ultimately obstruct blood flow. Although the other options are
risks, they are not considered the primary risk associated with AF. Other
potential life-threatening complications of AF include hardening of the
coronary arteries requiring increasingly higher blood pressures to bring
about effective coronary blood circulation, which likely will present long-
term cardiovascular health risks. Orthostatic hypotension resulting in
dizziness upon changing positions from lying to sitting or standing is a risk
for falls injury but is not considered life-threatening.

STEP 4
Considering Mrs. Hatfield’s identified health risks, it is appropriate for the
nurse to immediately notify her PCP and share concerns and assessment
findings. The client has been experiencing dizziness, so intervening to
minimize the risks of falling or other related injuries would be appropriate
at this time. Because a CVA (stroke) is the major risk of atrial fibrillation
(AF), it is important that the client understand the importance of healthy
eating and smoking cessation for minimizing the risk. Being familiar with
the signs/symptoms of a stroke would help ensure the initiation of early,
effective treatment. Appropriate physical activity is encouraged and helps
manage hypertension, but AF can be triggered by too much or inappropriate
physical activity, making a discussion about exercise more appropriate.

Generate Solutions
STEP 5
The nurse would first provide education on newly prescribed medication to
best assure client compliance with plan of care.
The primary concern is ensuring client compliance with the medication
therapy included in her new plan of care. By educating the client about the
actions, possible side effects, and expected outcomes of the medication, the
likelihood of the client’s active, appropriate participation with the plan of
care is greatly enhanced. Although implementing dietary recommendations
and providing emotional support for Mrs. Hatfield are important,
medication education is the priority. The nutritional recommendations are
focused on a long-term goal of weight loss. The emotional aspects of this
new diagnosis should be addressed as soon as the physiological aspects
have been addressed.

Take Action
STEP 6
☑ 1. “My heart hasn’t fluttered in more than a week.”

☑ 2. Client is wearing a nicotine patch on upper left arm.
☑ 3. The client is observed getting up from her chair slowly.
□ 4. “It’s been too cold to walk outside lately, but I’ll start again when its
warmer.”
□ 5. “It’s really difficult eating all the vegetables I’m supposed to have each
day.”
□ 6. “Now that Keith can get around more easily, things have been easier to
cope with.”
☑ 7. “We put our pills into these divided plastic containers; it has helped
me remember to take them.”
Evaluating the effectiveness of treatment focuses on statements and actions

that show improvement of symptoms and compliance with the treatment
plan. An extended period without symptoms—as well as compliance with
need to stop smoking, avoiding triggering dizziness, and implementing
strategies for effective administration of medication—all meet these
criteria. The client’s statements concerning the challenges surrounding
exercise and healthy eating are not supportive of her making the changes
identified in her plan of care. Although the statement concerning her
husband is positive, it has no direct association with either symptom
improvement or compliance with the treatment plan.

Evaluate Outcomes
Chapter 18: Digestion and Bowel
Elimination
STEP 1
The finding of greatest concern is a possible heart attack; that major

diagnosis has yet to be ruled out. Abdomen pain, distension, and rigidity
could relate to a possible bowel obstruction. These findings all related to
possible serious health issues that require immediate attention. Although
important, weight loss and heartburn are of less concern, and lack of BM is
likely related to the abdominal pain and distension.

Recognize Cues
STEP 2
Findings 1 and 6 are consistent with constipation and GERD, but not
typically with MI. Finding 2 is consistent with all three. Finding 5 is unique
to GERD, but it is not observed in clients with MI or constipation.

Analyze Cues
STEP 3
The client is at highest risk for developing constipation as evidenced by the
client’s last reported bowel movement “last week.”
Constipation by definition is associated with infrequent bowel movements.
Although the remaining conditions have existing symptoms identified, none
are as likely as the documented existence of constipation.

STEP 4
Interventions 1, 2, 3, 4, 5, and 6 are all indicated because based on the
change in the client’s condition, the nurse would retain intervention 5
(NPO), implement intervention 6 to relieve N/V, then apply implementation
1; obtain labs to obtain client’s baseline. After completion of intervention 4,
the nurse would implement interventions 3 and 2.
Intervention 7, Calcium 2,000 mg/d is contraindicated because the
recommended calcium intakes for age 70 and older is 1,200 mg/d. Calcium
toxicity includes gas, constipation, and bloating. In general, calcium
carbonate is the most constipating.
Intervention 8, Stress test is nonessential to client’s condition because stress
test is used to diagnose and evaluate heart problems such as ischemic heart
disease, heart valve disease, or heart failure, and client’s condition does not
fit these categories. Client was diagnosed with gastroesophageal reflux
disease (GERD), peptic ulcer disease (PUD), and gastritis.

Generate Solutions
STEP 5
The nurse will first administer ondansetron in order to stop the nausea and
vomiting.
The nurse would immediately administer ondansetron, which is meant to
stop client’s nausea and vomiting. The nurse would then administer a saline
laxative to facilitate a BM, followed by pantoprazole to initiate healing of
the esophagus.

Take Actions
STEP 6
Findings 1, 2, 3, and 4 indicate improvements in the client’s condition.
Finding 5 demonstrates a symptom of GERD that needs to be investigated
further. Finding 6 could indicate that the client’s glucose level has
improved.

Evaluate Outcomes
STEP 1
Finding 6 is an immediate concern for follow-up because it could indicate

the presence of the body’s response to an infection.
Finding 4 is also an immediate concern because pain is an abnormal
response generally indicative of disease, dysfunction, or damage to the
body.
Findings 2 and 3 are the next immediate concerns because they are
abnormal findings when considering normal human urine.
Findings 1 and 5 are not top findings because a history of diabetes does not
account for the described signs and symptoms, and glucose level is within
the normal range.
STEP 2
Findings 1, 2, and 5 are all consistent with signs and symptoms of UTI and
renal calculi. The symptom that stands out with UTI is the lower back pain
because typically, UTI affects the bladder region (and the bladder is located
on the lower back), whereas renal calculi presents with pain on one side of
the lower back or on the side beneath the ribs.
Finding 3 is associated with UTI, whereas urinary frequency is associated
with renal calculi.
Finding 2 is the only sign associated with hyperglycemia; urine has a fruity
odor.

Analyze Cues
STEP 3
The client is at highest risk for developing UTI as best evidenced by the
client’s unilateral lower back pain.
Assessment 3, unilateral lower back pain, is abnormal and is a classic
symptom of disorder 4, UTI.
Assessments 1, 2, and 4 are all presentations consistent with disorders 1, 3,
and 4.

STEP 4
Interventions 1, 2, 4, and 6 are all indicated associated with the assessment,
diagnostic work-up, and treatment of UTI.
Intervention 3 is questioned for because the client has diabetes, and the
consumption of cranberry juice with every meal will increase the client’s
blood glucose level, because cranberry is high in sugar.
Intervention 5 is nonessential because a high-protein supplement is not the
best evidence-based practice in treating UTI.

Generate Solutions
STEP 5
The nurse would first send urine to lab to confirm best antibiotic therapy.
The nurse would immediately implement STAT urine to lab before starting
the antibiotic Levaquin because the administration of the antibiotic could
alter the urinalysis result to a false negative. The nurse would then start the
antibiotic concurrent with the IVF of NS to help fight and flush the
antibiotic.

Take Actions
STEP 6
The client’s report of back pain relief and a temperature with the normal
range are relevant to recovery from UTI and show improvement.

Evaluate Outcomes
Chapter 20: Reproductive System
Health
STEP 1
Findings 1, 2, and 3 are of immediate concern because each is an abnormal

finding for a female of her age.
Findings 4 and 5 are not concerns because they are not abnormal findings
regarding the female breast, especially as the woman ages.
Finding 6 is not a concern because 6 hours of sleep nightly is considered
adequate.
STEP 2
Findings 1, 2, 3, and 4 can be associated with BPH. All are a result of

obstruction to urinary flow through the male urethra.
Findings 4 and 5 can be associated with ED. The main characteristic of ED
is an unsustainable erection that can be caused by hypertension.
Findings 1, 2, and 3 are associated with bladder dysfunctions caused by
nerve damage resulting from diabetes.

Analyze Cues
STEP 3
The female’s highest risk is for a diagnosis of breast cancer as evidenced by
her report of a solid breast lump.
Assessment 3, solid breast lump, is abnormal and is consistent with the
manifestation of disorder 2, breast cancer.
Assessment 1 can be associated with both malignant and benign breast
lesions.
Assessments 2 and 4 are not abnormal finding in the female breast.
Disorder 1 is not represented by any of the assessment findings.

STEP 4
Interventions 1, 3, 5, and 6 relate directly to Mr. Harding’s diagnosis and
medical treatment plan. Mr. Harding has several chronic medical diagnoses
that are likely to be treated with medications. It is important to note if any
are contraindicated by the alpha-adrenergic blocker tamsulosin. Tamsulosin
can cause orthostatic hypotension, so management strategies would be
appropriate. PSA would be the test ordered prior to the follow-up
appointment.
Interventions 2 and 4 have likely been addressed in the initial PCP
appointment and would appear in the client’s medical record.

Generate Solutions
STEP 5
The nurse would reinforce for Mrs. French that the purpose of the
mammogram is to detect breast masses in order to primarily assist in the
diagnosis of breast cancer.
A mammogram is not a substitute for manual breast examination but is a
diagnosis screening tool that is more sensitive than manual examination.
Although it is true that a mammogram is effective in finding very small
breast anomalies and that it presents results in a short time, its primary
function is to assist in the diagnosing of cancerous and benign breast
lesions.

Take Actions
STEP 6
NCSBN Clinical Judgment Measurement Model: Evaluate Outcomes
STEP 1
Maintaining a physically active state is more challenging in late life due to
the effects of aging and the symptoms and restrictions imposed by the
chronic health conditions that are highly prevalent among older adults.
Issues that impede physical activity can often cause respiratory,
musculoskeletal, and social problems for older clients. Such problems are
demonstrated by Mr. Radford’s statements and behaviors, as well as
statements his wife volunteered.

Recognize Cues
STEP 2
☑ 1. OA
☑ 2. Gout
□ 3. BPH
☑ 4. Psoriasis
☑ 5. Cataracts
☑ 6. Diverticulosis
☑ 7. Strawberry allergy
A variety of issues can be contributing to Mr. Radford’s immobility issues.

OA is the progressive deterioration and abrasion of joint cartilage, with the
formation of new bone at the joint surfaces. This pathology is a common
cause of impaired mobility, especially among the older population. Gout is
a metabolic disorder in which excess uric acid accumulates in the blood. As
a result, uric acid crystals are deposited in and around the joints, causing
severe pain and tenderness of the joint as well as warmth, redness, and
swelling of the surrounding tissue. Mobility is severely altered, especially
during acute attacks of gout. Psoriatic arthritis is a form of arthritis that
affects some people who have psoriasis. Mr. Radford’s diagnosed with
psoriasis presents a risk of the associated form of arthritis. A cataract is an
opacification of the lens of the eye, which leads to a decrease in vision. A
vision problem could contribute to the client’s mobility issues; in a direct
physical way but rather making it difficult to see sufficiently to feel safe
moving around. Diverticulosis is when pockets called diverticula form in
the walls of the digestive tract. Excessive diverticulitis can interfere with
the absorption of calcium, leading to osteoporosis. Osteoporosis leads to the
weakening of bones, resulting in an increased risk for fractures. Currently,
there is no research to directly associate either BPH or a strawberry allergy
to mobility issues.

Analyze Cues
STEP 3
Based on the client’s statements and history data, the client’s priority need
will be to establish an appropriate exercise program to prevent potentially
life-threatening complications of immobility, especially obesity and
pneumonia.
Mobility is one of the keys to a healthy, happy life, regardless of the usual
effects of aging and chronic illness. Being physically active through regular
exercise will contribute to less pain, increased muscle mass and strength, as
well as healthy lung function. Obesity and pneumonia are two serious
complications of immobility. The calories expended on exercise of any
form help to minimize the risk of obesity, and lung capacity is positively
affected by exercise. Although immobility can contribute to depression, the
life-threatening risk lies with the development of suicidal tendencies. The
client does not present with such risks. Pressure ulcers are a result of
extreme immobility that results in long periods of time being spent in
pressure-producing positions. Mr. Radford is not demonstrating such
extreme risks.

STEP 4
Answer(s):
Exercise programs should include actions to address the primary focuses of
exercise. These areas include endurance related to the heart, lungs, and
blood vessels’ ability to deliver oxygen to all body cells. Aerobic training
such as walking and swimming are excellent endurance exercises. Another
focus is flexibility. Flexibility, which encourages free movement of muscles
and joints, is achieved by moving these structures through a complete range
of motion and gentle stretching exercises. Yoga and calf stretches promote
flexibility. The final focus is strength training. Resistance and progression,
which are key elements in challenging muscles, are incorporated in wall
pushups and squats.

Generate Solutions
STEP 5
The nurse would first discuss the plan with the client’s PCP to make any
necessary changes based on existing health conditions.
Safety is the primary concern. The proposed exercise plan must first be
reviewed to ensure there are no known or suspected health-related issues
that would be exacerbated by the activities included in the plan. Although
the other options are appropriate, none have the priority of preapproval by
the client’s PCP.

Take Action
STEP 6
Mr. Radford’s lack of exercise was a result of several health issues, and the
resulting attitudes further exacerbated the risks for severe mobility-
associated health conditions. The follow-up conversations demonstrate a
change in some of these attitudes brought on by an improvement of
conditions and will help motivate him to continue the exercise program.

Evaluate Outcomes
STEP 1
Findings 1, 2, 4, and 5 are all factors that increase the client’s risk of injury;
Finding 1, BP 190/110 (elevated blood pressure) should be addressed
immediately to reduce further pathological effect.
Findings 3 and 6, although abnormal, are not immediate risks for injury.
STEP 2
Findings 1, 2, 4, and 5 are all consistent with both signs and symptoms of
TIA and CVA.
Finding 3 is consistent with Parkinson’s disease.

Analyze Cues
STEP 3
The client is at highest risk for developing CVA as evidenced by the client’s
prolonged expressive aphagia.
Assessment 3 (prolonged expressive aphagia) is consistent with the
manifestation of disorder 1 (CVA). Assessments 1 and 4 are consistent with
disorders 1 and 2.
Assessment 2 is consistent with disorder 3. Tremors in clients with
Parkinson’s are as a result of basal ganglia that are affected by the depletion
of dopamine, causing an involuntary movement.

STEP 4
Interventions 1, 3, 4, and 5 are all indicated because they are associated
with the assessment, diagnostic work-up, and treatment of CVA.
Intervention 2 is questioned for the client because the client could be
suffering from hemorrhagic stroke (bleeding), which occurs when a
weakened blood vessel ruptures. There are two types of CVA: ischemic
stroke (clots) occurs when there is an obstruction in the blood vessels that
supply blood to the brain, causing coagulation from the blood pooling. The
second type of CVA is hemorrhagic stroke (bleeding), which occurs when a
weakened blood vessel ruptures.

Generate Solutions
STEP 5
The client’s response to treatment is best identified by order 2 BP.
The status of the client’s BP would be the primary focus of labetalol IV 20
mg treatment effectiveness. The decrease from 190/110 to 140/90 indicates
effective treatment results.
None of the other options would be as directly related to the labetalol.

Take Actions
STEP 6
A decrease in blood pressure from 190/110 to 140/90 indicates effective
treatment results.NCSBN Clinical Judgment Measurement Model:
Evaluate Outcomes
STEP 1
Findings 1, 2, 3, and 4 are of immediate concern for follow-up because they

could indicate the presence of cataracts and glaucoma and increase his risk
for acute injury.
Findings 5 and 6 are not immediate concerns, as the other findings are.
STEP 2
Findings 1, 2, 3, 4, and 5 are all consistent signs and symptoms of cataract.

Findings 2, 3, 4, and 5 are all consistent with signs and symptoms of both
cataract and glaucoma.
Findings 1 and 5 are consistent with diabetic retinopathy.
Analyze Cues
STEP 3
The client is at highest risk for developing cataract as evidenced by the
client’s clouded, blurred vision and double vision.
Cataracts are associated with both clouded, blurred vision and possibly
double vision. Neither of the two remaining options are associated with
both of those characteristics.

STEP 4
☑ 1. Eating restrictions
☑ 2. Adjustments to existing medication therapies
☑ 3. Administration of preoperative medications
☑ 4. Transportation requirement on the day of surgery
□ 5. Need to schedule postsurgical follow-up for 48 to 72 hours postsurgery.
The preoperative instructions should include the need to hold certain

medication while providing instructions on appropriate administration of
specifically prescribed preoperative ones. Explaining restrictions
concerning food and liquid intake is vital in the prevention of aspiration
during the surgery. Some medications given to best prepare the client for
surgery will cause sedation, which will gradually wear off but which will
make driving oneself home after surgery unsafe. A post-op follow-up
should be scheduled within 24 hours after surgery.
Generate Solutions
STEP 5
The nurse would first begin administering prescribed medication therapies
to minimize development of infection or inflammation.
The priority intervention is to begin medication therapies directed at
minimizing the development of surgical site infection and inflammation.
Although the remaining options are appropriate, none have the priority of
infection and inflammation control.

Take Actions
STEP 6
Compliance is supported by the client’s wearing the eye patch and
volunteering that he isn’t lifting anything heavy. Progress is supported by
the client’s comments regarding minimal discomfort and lack of pain as
well as improved vision.

Evaluate Outcomes
STEP 1
Hyperglycemia is a common occurrence among older adults. Management

of glucose levels is vital to managing the chronic effects of this disease.
Medication adherence and a diet high in complex carbohydrates and fibers
controls the release of glucose into the bloodstream and can reduce insulin
deficiencies. It is vital that Mr. Angelo be adherent to both his medication
therapy and an appropriate diet to help best manage his diabetes.

Recognize Cues
STEP 2
The nurse recognizes that based on the client’s medical history and
assessment data, he is currently at risk for complications, related especially
to the function of the sensory, renal, nervous, and cardiovascular systems.
A variety of complications can affect older individuals who are living with
diabetes, and although there is a higher risk of problems developing in
virtually all body systems, several systems are commonly affected. Older
persons may develop neuropathies and are twice as likely to have increased
mortality rates from coronary artery disease and cerebral arteriosclerosis,
and a higher incidence of kidney and visual complications due to damage to
the microvascular structures supporting them. Although it is possible for
type 2 diabetes to damage the skeletal, muscular, and gastrointestinal
systems, these effects are less likely.

Analyze Cues
STEP 3
Based on the client’s condition and assessment data, the client’s priority
need will be to prevent coronary artery disease (CAD). In addition, he will
need interventions to prevent other chronic complications, especially renal
nephropathy and retinopathy.
Mr. Angelo’s diagnosis of diabetes presents him with twice the mortality
rate from coronary artery disease (CAD). The effects of micro- and
macrovascular changes places him at a high risk for the development of
both real disease and vision problems. Diabetic ketoacidosis (DKA) may
happen to anyone with diabetes, though it is rare in people with type 2
diabetes that are noninsulin dependent.

STEP 4
Mr. Angelo’s health-related issues focus on his need to assume control over
the management of his diabetes. His risk for complications is directly
impacted by an understanding of his disease and its management, his
weight, nonadherence to medication therapy, and unstable glucose levels.
Although the ability to cope with the disease is important, at present,
diabetes doesn’t seem to have a negative effect on Mr. Angelo’s quality of
life.

Generate Solutions
STEP 5
Mr. Angelo is taking responsibility for his health by planning meals in

accordance with dietary guidelines appropriate for the management of
diabetes as well as by actively engaging in an appropriate weight loss
program. The automatic refilling and delivery of his prescriptions will help
in ensuring medication compliance, and regular vision assessment will help
address possible diabetic-related complications. All of these actions
correlate with identified goals of his plan of care. Effective monitoring of
blood glucose levels should occur more frequently than once weekly.

Take Action
STEP 6
The hemoglobin A1c test (also called HbA1c, glycated hemoglobin test, or
glycohemoglobin) measures the amount of glycosylated hemoglobin in the
blood and is used to monitor the effectiveness of disease control.
Glycosylated hemoglobin is a molecule in red blood cells that attaches to
glucose. Hemoglobin A1c provides an average of the patient’s blood
glucose control over a 6- to 12-week period; the normal range is between
4% and 6%. For adults with diabetes, the goal is HbA1c below 7%. An A1c
of 6.4% best demonstrates the effectiveness of the client’s management of
his diabetes.

Evaluate Outcomes
STEP 1
The client has been admitted with acute health issues including a sacral
pressure injury, which additionally shows signs of inflammation. The client
is incontinent of urine and stool, which has contributed to both the pressure
injury and its inflammation. The client’s pain report is high and requires
immediate attention. The client’s temperature is slightly elevated. Mr.
Baldwin’s prealbumin, albumin, BUN, and WBC results also indicate acute
health-related needs.

Recognize Cues
STEP 2
The nurse recognizes that based on the client’s assessment findings, the
client is currently at greatest risk for complications, especially related to
pain, infection, impaired nutrition, and impaired wound healing.
The client’s current pain assessment clearly indicates a need for effective
pain management for both the cancer pain and soft tissue damage. WBC
count and slightly elevated temperature supports the risk for and possible
existence of acute infection. Impaired nutrition and impaired wound healing
are both supported by the client’s BUN, prealbumin, and albumin levels.
Although bone fractures and additional metastasis are possible, neither
present with the risk of possible complications supported by assessment
findings.

Analyze Cues
STEP 3
Based on the client’s condition and assessment findings, the client’s acute
priority need will be to achieve effective wound healing. In addition, he will
need interventions to prevent potentially life-threatening complications of
infection, especially pneumonia, UTI, and sepsis.
The most acute risks to the client’s general health are associated with the
poor wound healing of his sacral pressure injury. The continuation of this
situation stresses the client’s other body systems and dramatically increases
the risk of serious infections. The risk for pneumonia is supported by the
client’s immobile state and existence of a low fever and elevated WBC
count. UTI is supported by urinary incontinence and the aforementioned
fever and WBC count. Sepsis is possible due to the client’s weakened state,
and increased potential for an infected wound bed, pneumonia, and UTI.
Although the client has experienced cancer metastasis to the bone,
osteomyelitis is not a primary concern unless the ulceration reaches down to
the sacral bone itself (stage 4).

STEP 4
☑ 1. Client’s surgical wound will be assessed as being in the maturation

phase of healing.
☑ 2. Client will be able to effectively consume diet to achieve desired
prealbumin level goal.
□ 3. Client will demonstrate a weight gain of between 4 and 6 lb.
☑ 4. Client’s albumin level will be within normal range.
☑ 5. Client’s BUN level will be within normal range.
□ 6. Client’s BMI will be within normal range.
☑ 7. Client’s WBC will be within normal range.
The client is currently demonstrating a protein deficiency, which will affect

postsurgical wound healing. Option 1 is relevant because during the
maturation phase of wound healing, the new tissue slowly gains strength
and flexibility; collagen fibers reorganize, the tissue remodels and matures,
and there is an overall increase in tensile strength (although maximum
strength is limited to 80% of the preinjured strength). Normally, it takes up
to 3 weeks to enter into this phase and from 21 days to 2 years to complete.
Options 2, 4, and 5 show achievement of normal levels of prealbumin,
albumin, and BUN; all are markers for evaluating wound healing. The
values given as options all reflect normal levels and so would indicate the
likelihood of effective wound healing. Option 7 demonstrates that an
infection is not likely. Although the stated goals related to the remaining
options are appropriate, neither weight gain nor BMI is related to wound
healing. With the client’s diagnosis of metastasis lung cancer and age,
weight gain is not likely.

Generate Solutions
STEP 5
Effective wound healing require focus on actions that support the client’s
physiological ability to regenerate epithelial tissue and the prevention of
further pressure on the sacral area. The nutritional consultation will help
effectively provide adequate intake and absorption protein, a vital
component in tissue regeneration and repair. Turning and repositioning the
client every 2 hours will help minimize the effects of tissue anoxia and
ischemia resulting from prolonged pressure on the injured area. The wound
consult will help arrive at the most effective wound care protocol to
facilitate wound healing for a stage 2 pressure injury. The insertion of the
Foley catheter will help keep the sacral area dry, which will facilitate the
healing process and minimize the risk for further skin damage. The catheter
should be removed as soon as healing goals are reached. The other two
options are not appropriate here; IV morphine administration is directed at
pain control, and IV ciprofloxacin is prescribed to manage the risk of
wound infection.

Take Action
STEP 6
The wound itself is demonstrating healing with 70% tissue regeneration and
resolution of the initial inflammation. Client’s temperature is within normal
limits, likely indicating lack of an infection. BUN, prealbumin, albumin,
and WBC results are all within normal limits. All these indicators suggest
that the client’s health issues related to the pressure injury are resolving.

Evaluate Outcomes
Chapter 26: Cancer
STEP 1
Cancers are varied, as are their causes. Mrs. Janes’ age and her history of a
prediabetic condition are risk factors for cancer. Smoking, as well as
working with pesticides for years, are known carcinogens, raising her risk
factors. An extended family history of various cancers is also a red flag that
needs further assessment. Her surgical and childbirth history are not
concerning.

Recognize Cues
STEP 2
☑ 1. “Have you experienced any uterine bleeding since completing

menopause?”
☑ 2. “Have you had any changes in your bowel habits lately?”
☑ 3. “How long does it usually take for a cut to heal?”
☑ 4. “Is indigestion or bloating a problem for you?”
□ 5. “When did you have your last mammogram?”
☑ 6. “May I look at any warts or moles you have?”
☑ 7. “Do you have any difficulty swallowing?”
□ 8. “Have you ever had a colonoscopy?”
Appropriate questions would assess changes in bowel or bladder habits,

sores that do not heal, unusual bleeding or drainage, indigestion or
swallowing difficulty, or an obvious change in a wart or mole. Questions
concerning thickening or a lump in the breast or elsewhere are appropriate,
but merely determining when the client last had a mammogram does not
establish the presence of such a problem currently. Similarly, it is
appropriate to inquire about changes in bowel habits and if there is blood in
the stool, but ascertaining only if the client has ever had a colonoscopy is
insufficient to determine the presence of warning signs.

Analyze Cues
STEP 3
Mrs. Janes’ weight (BMI of 25 = overweight), history of smoking,

prediabetes diagnosis, and history of working outdoors increases her risk
for certain cancers. Actions indicated with a check mark are related to those
risks and are therefore important to her personal cancer prevention strategy.
Although exercise and diet are factors as well, it is not necessary to exercise
daily or to follow a vegan diet to achieve weight loss, stable blood sugar
levels, or general wellness.

STEP 4
All the actions indicated with a check mark correlate with previously
identified areas of priority prevention. By adding these actions to the
client’s plan of care, specific prevention needs will be targeted for
management. It would not be appropriate to replace prescribed medications
with herbal alternatives without extensive discussion with the primary
health care provider.
Generate Solutions
STEP 5
The nurse would first demonstrate the application of a nicotine patch and
then evaluate the client’s understanding of the process to help minimize
Mrs. Jane’s risk for lung cancer.
The risk for lung cancer related to Mrs. Jane’s smoking is an active, acute
one. The need for her to stop smoking is critical if she is to begin to manage
her risk. Although the other options are appropriate, weight loss, glucose
level management, and cancer screening are focused on actions that are
supportive of cancer development prevention or detection but not on
actively managing an acute risk.

Take Action
STEP 6
The prevention plan will be effective only if Mrs. Jane is motivated to be
adherent. The statements concerning the patch, cancer screening, and desire
not to develop cancer show both motivation and adherence. The statements
related to diet and exercise do not demonstrate either motivation or
likelihood of adherence.

Evaluate Outcomes
Chapter 27: Mental Health
Disorders
STEP 1
The emergency department nurse should identify dyspnea as the client’s
primary presenting problem followed by palpations based on the client’s
physical assessment.
Physical complaints (reported or observed) should be addressed before

psychosocial signs/symptoms. Issues (“…it’s hard to catch my breath” and
“My heart is beating really, really hard…”) should be addressed in the order
they are physically assessed (Airway, Breathing, Circulation). The client’s
fears regarding experiencing either a heart attack or being infected with
COVID-19 would then be addressed.

Recognize Cues
STEP 2
Rationales: Anxiety disorder presents with cognitive arousal, specifically

including a heightened startle reflex and a narrowed perceptual field that
requires redirection at times. This client is focusing on the possibility of
either having a heart attack or being infected with the COVID-19 virus.
Nausea, palpitations, dyspnea, and hypertension are characteristics of either
anxiety or a possible heart attack. The client’s age is not specific to any
particular diagnosis being considered.

Analyze Cues
STEP 3
☑ 1. States, “I’m not afraid; it’s my mother who is so scared of dying from
it.”
☑ 2. Now shows hesitation verbalizing concerns related to COVID-19.
☑ 3. Increase in typical alcohol consumption.
□ 4. Heart rate 110
□ 5. History of eczema.
□ 6. Hyperpnea.
Defense/coping mechanisms are used to reduce anxiety by preventing or

diminishing unwanted thoughts and feelings. They can be useful in coping
with everyday problems, but they become problematic when overused.
Suppression is intentionally avoiding thinking about the disturbing problem,
such as the client’s tendency to showing hesitation about discussing the
virus. Projection assigns unwanted thoughts and feelings to another person,
such as when the client claims it is his mother who is worried about dying
from the virus. Denial, such the client’s statement that “I’m not afraid,”
exhibits an avoidance of feelings associated with a problem. The client may
be demonstrating sublimation when drinking too much in order to avoid his
fear of contracting the virus.

STEP 4
☑ 1. “Are you currently treating your eczema?”

☑ 2. “Do you use any recreational drugs?”
□ 3. “Do you consider yourself a religious individual?”
☑ 4. “How much coffee, tea, and soda do you consume on an average
day?”
☑ 5. “Are you experiencing any problems getting 6 to 8 hours of sleep
nightly?”
□ 6. “Are you currently experiencing any problems with bowel
elimination?”
□ 7. “Do you have an established relationship with a primary health care
provider?”
☑ 8. “Would you describe your alcohol drinking habits over the last several
weeks?”
Key assessment areas of physical health include the use of legal or illegal
substances that are known to precipitate a panic attack, current sleep
patterns, and all acute or chronic health conditions. Caffeine and cocaine
may trigger a panic attack. Many individuals use alcohol or central nervous
system (CNS) depressants in an effort to self-medicate anxiety symptoms;
withdrawal from CNS depressants may produce symptoms of panic.
Fatigue may increase anxiety and susceptibility to panic attacks, so a sleep
assessment is appropriate. Steroids often prescribed for eczema are known
to cause increased levels of anxiety. Although a problem with constipation
or diarrhea would require attention, neither is known to trigger panic
attacks. Inquiring about a client’s religious preferences is appropriate;
however, such information would have little bearing of identifying panic
triggers.

Generate Solutions
STEP 5
☑ 1. Teach relaxation techniques.

☑ 2. Discuss benefits of meditation.
☑ 3. Teach controlled breathing exercises.
☑ 4. Discuss the options of medication therapy.
☑ 5. Encourage to begin slowly limiting caffeine consumption.
☑ 6. Identify three ways to engage in appropriate regular exercise.
☑ 7. Discuss effective support strategies available to the client’s spouse.
It is important to manage stress and anxiety when addressing interventions

for minimizing and controlling the recurrence of panic attacks. Effective
interventions include the effective implementation of controlled breathing
and relaxation techniques including meditation and regular exercise.
Limiting consumption of known anxiety-inducing substances such as
caffeine will also help minimize possible triggers. Medication compliance is
key to the management of anxiety and related panic attacks. An effective,
caring support system is vital to the management of anxiety.

Take Action
STEP 6
A change to a client’s plan of care is warranted when goals have not been
met. In this case, because the client continues to experience panic attacks
even though he is employing effective management techniques, new and/or
additional interventions are needed. The client requires addition education
regarding the benefits of regular exercise and absenting from alcohol,
tobacco, and caffeine, because all these are known as anxiety triggers.
Appropriate weaning from these substances is necessary because abrupt
withdrawal can also trigger anxiety and panic attacks. The client’s spouse
requires additional discussion and education concerning means of providing
effective support to the client without feeling frustrated or experiencing
burnout. Finally, the side effects from decongestant medications may
include a fast heart rate, rapid breathing, chest discomfort, increased
sweating, blurred vision, and dizziness. All of these adverse reactions can
mimic the symptoms of anxiety and, in sensitive individuals, may even
precipitate panic attacks. A discussion concerning appropriate decongestant
use is necessary to help minimize these effects.

Evaluate Outcomes
Chapter 28: Delirium and
Dementia
STEP 1
Dementia is a progressive, irreversible impairment in cognitive function

affecting memory, orientation, judgment, reasoning, attention, language,
and problem-solving. It is caused by damage or injury to the brain.
Alzheimer’s disease is the most common form of dementia. The symptoms
of this progressive, degenerative disease develop gradually and progress at
different rates among affected individuals. The highlighted portion of Mr.
Downey’s assessment indicates a progressive deterioration of both his
cognitive and physiological condition. The issues highlighted require
immediate follow-up by the nurse because they increase his risk for injury
related to safety, nutritional, and urinary concerns.
STEP 2
Mr. Downey has been identified as being at risk for nutritional, sleep, and
urinary problems. The risk for physical injury is associated with his
tendency to wander as well as the three risks just mentioned—i.e.,
nutritional, sleep, and urinary problems. Mr. Alvera has presented with
possible nutritional and sleep-related health risks. In addition, there is
reason to suspect possible depression and ineffective stress management
issues. The assessment fails to identify any risk for suicide for either Mr.
Downey or Mr. Alvera, but such assessments should be conducted at future
visits.

Analyze Cues
STEP 3
Based on the client’s assessment findings and Mr. Alvera’s interview
statements, the priority need for Mr. Alvera is to prevent the development
of depression. In addition, Mr. Alvera will need interventions to prevent
additional stress, especially related to the role of caregiver and
understanding of the disease process.
Assistance and support to the families of patients are integral parts of
nursing care for persons with dementia. The physical, emotional, and
socioeconomic burden of caring for a relative with cognitive impairment
can be overwhelming, especially with competing responsibilities such as
work and other family caregiving responsibilities. The nurse should also
help prepare families for any guilt, frustration, anger, depression, stress, and
other feelings that may accompany caregiving responsibility. Depression is
common among caregivers, especially those who lack an understanding of
their role and its challenges as well as an understanding of the chronic
health issue they are facing.

STEP 4
□ 1. Client will remain free from injury.
□ 2. Care will be provided in a consistent manner.
□ 3. An establish toileting routine will be instituted.
□ 4. Weight will be maintained within the ideal range.
☑ 5. Client will sleep 5 to 7 hours nightly, with one daytime nap.
☑ 6. Client will be enrolled in a local adult day care program.
☑ 7. Alzheimer’s Disease and Related Disorders Association will be
utilized as a resource.
Mr. Alvera has been identified as having issues that are focused on a lack of
sleep and stress related to the care of his spouse. Striving to ensure that Mr.
Downey consistently sleeps 5 to 7 hours nightly will help provide adequate
sleep for Mr. Alvera. Mr. Downey’s enrollment in a local adult day care
program will afford his spouse an opportunity to have a respite from the
stress of caregiving. Services offered by local agencies will also contribute
to Mr. Alvarez’s understanding of Alzheimer’s disease and provide
strategies to best meet the needs of both the client and family members. The
remaining options are client-focused, rather than caregiver-focused, in their
attempt to prevent physical injury, provide consistent care, and promote
effective urinary elimination.

Generate Solutions
STEP 5
In order to best address Mr. Alvera’s identified needs, the nurse would first
thoroughly address all issues. Mr. Alvera has concerning the effects,
progression, and prognosis of Alzheimer’s disease to provide an appropriate
basis for addressing Mr. Downey’s care now and in the future.
Addressing the needs and problems that occur over the course of Mr.
Downey’s illness will help promote dignity and quality of life for him and
will help decrease the stress or burden Mr. Alvera experiences. Effective
use of community resources, as well as realistically recognizing the
challenges that are likely to exist in the future, are both components of
effective care, supported by Mr. Alvera’s knowledge and understanding of
the disease process.

Take Action
STEP 6
The nurse notes that Mr. Downey appears calm and cooperative although
detached from the conversation. Mr. Alvera confirms that his husband has
been eating better and even regained 1 lb since the last visit. He is also
sleeping at least 6 hours a night which allows Mr. Alvera to rest
uninterrupted most nights. The Alzheimer’s Disease and Related Disorders
Association representative suggested applying safety locks to the outside
doors which have helped prevent Mr. Downey from wondering outdoors
and has provided Mr. Alvera with “much peace of mind.” Mr. Downey has
been attending an adult day care program 2 afternoons a week. The
experience created some disruption in their daily routine originally, but Mr.
Alvera feels they are settling into the new routine well. He shared that he
uses the time alone to read, to engage in some gardening, or to visit with
friends. When asked about long-term care for his husband, Mr. Alvera
responded that, “It isn’t necessary yet, but I’ll be open to the possibility in
the future if needed.
Rationales: Both the Mr. Downey and Mr. Alvera appear calmer. The
interventions regarding community services and understanding of the
disease process have provided Mr. Alvera with a less stressful environment
that he has more control over.

Evaluate Outcomes
Chapter 29: Living in Harmony
With Chronic Conditions
STEP 1
Illness is not an easy situation to accept. Chronic conditions will
accompany people for the remainder of their lives and will potentially affect
every aspect of one’s life. Because chronic conditions are highly prevalent
in the older population, nurses often are involved in assisting patients with
the demands imposed by these conditions. Mr. Petrovich’s appearance, lack
of personal hygiene, and—most importantly—failure to adhere to his
medication treatment plan and PCP follow-up visits indicate that he is in
need of assistance to fully reach his health and wellness potential.

Recognize Cues
STEP 2
The nurse recognizes that based on the client’s list of chronic illnesses and
assessment findings, he is currently at risk for complications, especially
stroke, lung infections, and falls.
Mr. Petrovich’s history of hypertension increases his risk of stroke. This
risk is currently being heightened by his nonadherence to his medication
therapy. Osteoarthritis, glaucoma, and macular degeneration increase his
risk for falls, and chronic obstructive pulmonary disease (COPD) is a factor
in the development of lung infections. His assessment fails to provide
support for possible anxiety or pressure injuries.

Analyze Cues
STEP 3
Mr. Petrovich’s assessment produced findings that support a current risk for
injury related to both falls and possible stroke. His history of COPD is a
serious factor related to respiratory infection. Client’s statement referring to
“lacking energy” strongly suggests a reduction in mobility, whereas his
noted lack of physical hygiene supports a reduction in the ability for self-
care. Although some of his medical diagnoses could cause pain, the client
did not mention it during the visit. The client currently has a reasonably
good relationship with his family, supported by their frequent
communications. There is no evidence to suggest confusion from this
assessment.

STEP 4
Currently, Mr. Petrovich is demonstrating poor hygiene practices, which
suggests a need for interventions to improve his attention to these needs.
His lack of adherence with medical therapy and follow-up medical care
demonstrates a need to address the prevention of complications. His current
assessment indicates evidence of a decline in self-care and management of
his health issues that requires immediate intervention. At present, there is
no indication that his body is demonstrating a deficit in healing abilities,
especially because he presented with no evidence of acute illness. There
should not be an expectation of disease cure, because his diagnoses are all
chronic in nature. Although dying with comfort and dignity is an
appropriate goal, it is premature in Mr. Petrovich’s situation.

Generate Solutions
STEP 5
To best address the client’s needs, the nurse would first arrange to have Mr.
Petrovich’s medication refills automatically delivered to his home to
facilitate the effectiveness of his medication therapies.
The client’s most acute health need is adherence to his medication
therapies; this can best be met by arranging for his medications to be
refilled and delivered to his home without interruption. Although the other
options are appropriate, the acute nature of medication adherence has
priority.

Take Action
STEP 6
The notes clearly indicate that Mr. Petrovich is receiving his medication
refills effectively as well as keeping his medical appointments. He is more
socially and physically involved than was previously noted. His physical
appearance and hygiene also show improvement. All these observations
indicate an improvement in self-care, mobility, and avoidance of disease-
related complications.
Evaluate Outcomes
Index
Note: Page numbers followed by “f” indicate figures, “b” indicate boxed
material, and “t” indicate tables.
A
AARP. See American Association of Retired Persons (AARP)
Abdomen, physical examination of
Abdominal aortic aneurysms
Abscess, lung
Absolutism
Abuse
alcohol
elder
family dysfunction and
Acarbose
ACE. See Angiotensin-converting enzyme (ACE) inhibitors
Acetaminophen
Acquired immunodeficiency syndrome (AIDS)
Acral lentiginous melanoma
ACTH. See Adrenocorticotropic hormone (ACTH)
Activities of daily living (ADL)
Activity and exercises. See also Safety
aging and risks
cardiovascular endurance
creativity
effects of inactivity
flexibility
heart rates during
inactivity prevention
reduced mobility
social support and
strength training
Activity theories
Acupressure
Acupuncture
during menopause
Acute appendicitis
Acute care
discharge planning
emergency care
infections
older adult, hospitalization of
surgical care
Acute pain
AD. See Alzheimer’s disease (AD)
Adrenocorticotropic hormone (ACTH)
Adult day services
Adult education
Adult foster care
Advance directives
Advocacy, holistic care
Advocate, nurse as
Affordable Care Act
Age stratification theories
Ageism
Age-related changes
in attention span
in cardiovascular system
in cells
chronic aerobic exercise
in endocrine system
in gastrointestinal system
in hearing
in immune system
in integumentary system
in intelligence
in learning
in memory
in musculoskeletal system
in nervous system
in nursing implications
in personality
in physical appearance
in reproductive system
in respiratory system
in sensory organs
and sexual response
skeletal changes
in sleep
in taste and smell
in thermoregulation
in touch
in urinary system
in vision
Aggressive antihypertensive therapy
Aging. See also Age-related changes
Baby Boomers, impact of
effects of
endocrine system
factors influencing
long and healthy life
natural process
provision of and payment for services
psychosocial challenges of
reminiscence
survivor competencies
theories of
activity
age stratification
antagonistic pleiotropy
biological
continuity
cross-linking
developmental tasks
disengagement
disposable soma
environmental
evolutionary
free radicals and lipofuscin
genetic
gerotranscendence
mutation accumulation
neuroendocrine and neurochemical
nonstochastic
nursing practice
nutrition
psycho-behavioral factors
psychological
radiation
sociologic
stochastic
subculture
successful aging
thriving
wear and tear
vision and hearing
Aging services technologies awareness
Agnostic
AIDS (acquired immunodeficiency syndrome)
in black Americans
Alcohol abuse/use
Alcohol Use Disorders Identification Test (AUDIT)
Alcoholism, impaired cognition and
Aldosterone
Allergy, drug
Allopurinol, food and drug interactions with
Almshouse
Alpha-blockers
Alternative and complementary therapies
cancer
comfort
healing partnerships
hope
relationship-centered care
support
chronic illness
continuum of care
dementia
menopause
skin health
Alzheimer’s disease (AD)
mild cognitive impairment
older adult with
person caring
possible causes
stages
symptoms
treatment
American Association of Retired Persons (AARP)
American Cancer Society
American Journal of Nursing
American Nurses Association (ANA)
Ampicillin
Anabolic sex hormones, reduction in
Analgesics
Andropause
Anemia
drug-related
impaired cognition and
Aneurysms
Anger
Angina
Angiotensin-converting enzyme (ACE) inhibitors
Ankle
physical assessment of
range-of-motion
assessment of
exercises
Anorexia
drug-related
Antacids
food/drug interactions with
Antagonistic pleiotropy theories
Antianxiety drugs (anxiolytics)
drug interactions with
Antibiotics
Anticholinergic effects
Anticoagulants
Anticonvulsants
Antidepressants
Antidiabetic (hypoglycemic) drugs
Antihistamines, food and drug interactions with
Antihypertensive drugs
Anti-inflammatory agents, drug interactions with
Antipsychotics
Antithrombotics
Anxiety
Apnea, sleep
Apoptosis
Appendicitis
acute
Appetite, gastrointestinal function and
Arachidonic acid
Aromatherapy
Arrhythmias
Arteriosclerosis
Asian Americans
Asian Groups
Aspirin, food and drug interactions with
Assault
Assemblies of God (Pentecostal), beliefs and practices
Assistance with chores
Assisted living facility
Assisted suicide
Assistive technology
Asthma
Atelectasis
Atheist
Atherosclerosis
Athlete’s foot
Atrial fibrillation
Attention span, age-related changes in
AUDIT (alcohol use disorders identification test)
Autonomy
Ayurvedic medicine
B
Baby boomers
generation of
impact of
Babysitting
Balanced Budget Act of 1997
Baptist, beliefs and practices
Battery
Beers criteria
Benchmarking
Beneficence
Benign prostatic hyperplasia
Bile acid resins
Biliary tract disease
Biofeedback
Biogerontology
Biological clock
Biological half-life
Biological theories
Bisexual
Black Americans
Bladder cancer
Blood dyscrasias
Blood pressure
decreased
elevated
monitoring in Black Americans
sleep-disordered
Body fluid
Body temperature
age related changes in
in cardiovascular disease
Body transcendence vs. body preoccupation
Body weight, measurement of
Botox injections
Bowel elimination. See Gastrointestinal system
Brachial pulse
Bradykinesia
Brain death
BRCA
Breast cancer
Breathing. See also Respiratory system
cardiovascular function
reduced capacity
Bronchiectasis
Bronchitis, chronic
Bronchodilators
Brujos
Buddhism, beliefs and practices
Buerger-Allen exercises
Bulk formers
Bunions (hallux valgus)
Burial arrangement
C
Calcium
good sources of
recommended intake of
supplements, food/drug interactions with
Calcium channel blockers
Calluses
Caloric needs, quantity/quality of
CAM. See Complementary and alternative medicine (CAM)
Cancer
aging and
of breast
CAM
of cervix
colorectal
complementary and alternative therapy
conventional treatment
of endometrium
esophageal
lung
older adults with, nursing considerations
of ovaries
of pancreas
of prostate
risk factors, prevention and screening
screening of
skin
of stomach
of vagina
Canes
Carbenicillin
Carbohydrates
Cardiac arrhythmias
Cardiac failure
Cardiac function, decreased, impaired cognition
Cardiovascular disease
dietary guidelines for reducing risk
Cardiovascular endurance
Cardiovascular system
age-related changes in
angina
arrhythmias
atherosclerosis
atrial fibrillation
complementary therapies for
congestive heart failure
coronary artery disease
C-reactive protein screening
disease and women
effects of aging
good tissue health
and risks to adequate circulation
foot care
function of
health promotion
adequate exercise
cigarette smoke avoidance
Ornish’s diet
proactive interventions
proper nutrition
stress management
hyperlipidemia
hypertension
hypotension
levels of, prevention
myocardial infarction
older adult with heart failure
patient education
peripheral vascular disease
physical deconditioning
preventing complications in
promoting circulation
promoting normality
pulmonary emboli
selected conditions
Caregivers
burden
education
program
Caregiving
family dynamics and relationships
family dysfunction and abuse
family member
identification
roles
health protection
long-distance caregiver
nursing strategies
older adult’s family
rewards of
scope of
Cascara sagrada
Case management
Cataracts
Celecoxib
Cells, age-related changes in
Centers for Disease Control and Prevention (CDC)
Central nervous system disturbances, impaired cognition and
Cephalosporins
Cerebrovascular accident (CVA)
older adult with
Cervical cancer
Cervix, problems of
Chair position
Child care, by grandparents
Childrearing
Chinese Americans
Chinese Medicine
Chiropathy
Chiropractic
Chlorpropamide
Cholelithiasis
Cholesterol absorption inhibitors
Cholesterol-lowering drugs
Cholinesterase inhibitors
Christian Church (Disciples of Christ), beliefs and practices
Christian Science, beliefs and practices
Chromium
Chronic aerobic exercise
Chronic bronchitis
Chronic care coach
Chronic constipation
Chronic illness
assessment of
chronic care coach
complementary and alternative therapies for
defense mechanisms and implication
factors affecting
goals in
increasing knowledge of
institutional care
nursing challenge
older adults
ongoing care on the family
physician selection
psychosocial factors
smart lifestyle choices
support group
Chronic obstructive pulmonary disease (COPD)
asthma
chronic bronchitis
depression in patients with
emphysema
lung cancer
older adult with
Chronic opioid use
Chronic pain
Church of the Brethren, beliefs and practices
Church of the Nazarene, beliefs and practices
Cigarette smoking, cardiovascular health and
Cimetidine, food and drug interactions with
Circadian rhythms
Circadian sleep-wake cycles
Circulation. See Cardiovascular system
Clonidine, food and drug interactions with
Closeness and trust, spirituality
Coenzyme Q10 (CoQ10)
Cognitive enhancing drugs
Cognitive impairment
Cognitive limitations
Colchicine, food and drug interactions with
Colorectal cancer
Comfort. See also Pain
acupressure
massage
quality time with patient
touch therapies
Communication techniques, modified
Comorbidity
Competencies
gerontological nursing
patient
survivor
Complementary and alternative medicine (CAM)
chronic illness
comfort
dementia
healing partnerships
hope
relationship-centered care
support
Complementary therapies. See Alternative and complementary therapies
Compression of morbidity
Confidentiality
Conflict of interest
Confusional states, acute
Congestive heart failure
Connections, strategies in older adults
Consent
Conservatorship. See Guardianship
Constipation
chronic
drug-related
dying individual
Consumer affairs
Continence, activities of daily living assessment and
Continuing care retirement communities (CCRCs)
Continuity theories
Continuum of care
complementary and alternative services
complete and continuous care services
continuing care retirement communities
matching services to needs in
for older adults
partial and intermittent care services
supportive and preventive service
Contractures
Convalescence period
Corneal ulcer
Corns
Coronary artery disease
angina
fitness programs
myocardial infarction
Cost-analysis
Coughing
productive
Counseling
C-reactive protein screening
Creutzfeldt–Jakob disease
Criminal negligence
Cross-linking theories
Crystallized intelligence
Culture
Cumulative Index to Nursing Literature
Curanderos
Cyclooxygenase-II (COX-2) inhibitors
D
Day hospital programs
Day treatment
Death and dying. See also Mortality, awareness of
advance directives
family support
friend support
helping after death
hospice care in
nursing problems
pain management
physical care challenges
constipation
pain
poor nutritional intake
respiratory distress
rational suicide and assisted suicide
signs of
spiritual care needs
stages of
acceptance
anger
bargaining
denial
depression
Deep-breathing exercises
Deep tissue damage
Defamation of character
Defense mechanisms
Dehydration, impaired cognition and
Delirium
Dementia
AIDS
Alzheimer’s disease
caring for persons with
communication techniques, modified
complementary and alternative therapies
Creutzfeldt–Jakob disease
frontotemporal
HIV-related
Lewy body
older adult with, nursing care plan
patient safety
patient’s family
physical care
respecting the individual
sundowner syndrome
therapy and activity
trauma and toxins
vascular
Wernicke’s encephalopathy
Denial
Dental problems
Dentin
Depression
antidepressants
caring for depressed patients
drugs that can cause depression
geriatric depression scale
signs and symptoms
suicide risk
treatment
Detached retina
Developmental tasks theories
Diabetes mellitus (DM)
care plan goals
complications
content for diabetic patient education
diagnosis
drug therapy
Dupuytren contracture
exercise and nutrition
general guidelines for patient education
hemoglobin A1c test
insulin preparations
management of the illness
metabolic syndrome
noninsulin drugs
nursing problems
overweight and obese people
patient education
patient self-care and monitoring
finger-prick method
triglyceride monitoring
type 2
Diarrhea
drug-related
Diazepam
Dicumarol, food and drug interactions with
Diet. See also Nutrition
DASH
Kosher
during menopause
Ornish’s
Dietary Approaches to Stop Hypertension (DASH) diet
Digestion and bowel elimination. See Gastrointestinal system
Digitalis, food and drug interactions with
Digitalis toxicity
Dignity, spirituality
Digoxin
Disability
attitude
coping capacity
losses accompanying disability
Discharge planning
Disengagement theories
Disposable soma theories
Diuretics
Diversity
Chinese Medicine
increasing
LGBTQ
nursing considerations for culturally sensitive care
nurses’ feelings and attitudes
patients’ feelings and attitudes
in the United States
Diverticular disease
Diverticulitis
Do not resuscitate (DNR) orders
Dorsalis pedis pulse
Doxycycline
Dressing, activities of daily living assessment and
Drug(s)
absorption
alternatives to
Beers Criteria
distribution
effects of aging
food and drug interactions
metabolism, detoxification, and excretion
monitoring laboratory values
necessity and effectiveness of
patient teaching
pharmacodynamics
pharmacokinetics
polypharmacy and interactions
popular drug groups
review of selected drugs
risk factors for medication errors
risk of adverse reactions
safe and effective administration
tips for
Dry mouth (xerostomia)
Dupuytren contracture
Durable power of attorney
Duty
Dysarthria
Dyspareunia
Dysphagia
esophageal
oropharyngeal
Dysphasias
E
Eastern Orthodoxy, beliefs and practices
Eating. See also Diet; Nutrition
activities of daily living assessment and
Economic issues, affecting older adults
Edema
Education, holistic care
Educational limitations
Educator, nurse as
Egoism
Elastic recoil
Elbow
range-of-motion
assessment of
exercises
Elder abuse
Electrical stimulation
E-mails
Embolism
pulmonary
venous
Embryonic tissue injection
Emergency care
Emotional homeostasis
Emphysema
Employment
Endocrine system
diabetes mellitus
effects of aging on
hyperthyroidism
hypothyroidism
practice realities
End-of-life care. See also Death and dying
changes in birth and death rate
definitions of death
family experience with dying process
hospice
supporting dying individual
supporting family and friends
supporting nursing staff
Endometrial cancer
Environment
assessment checklist
bathroom hazards
colors
fire hazards
floor coverings
furniture
to health and wellness
lighting
Maslow’s hierarchy
noise control
potential environmental impact
psychosocial considerations
scents
sensory stimulation
temperature
Environmental hazards
Environmental theories
Epidermis
Episcopal, beliefs and practices
death related
Erectile dysfunction
Erikson’s developmental tasks
Error theory
Esophageal cancer
Esophageal dysphagia
Espiritualistas
Essential fatty acids
Established incontinence
Estrogen, food and drug interactions with
Ethical decision-making
Ethical dilemmas
Ethics
assisted suicide
code of
conflict of interest
cultural considerations
definition
expanded role of nurses
external and internal standards
Fiscal constraints
in gerontological nursing
increasing older adults
medical technology
principles of
Ethnic groups
Ethnogeriatrics
Ethnography
Evidence-based practice
Evolutionary theories
Exercises
aging and risks
calculating heart rates
cardiovascular endurance
to do anytime
to do while in bed
flexibility
Kegel
programs for older adults
range-of-motion
assessment of
exercises
strength training
Extrapyramidal symptoms
Eyes
in nutritional assessment
sensory function
F
Faith, spirituality
False imprisonment
Family and friends
grandparenting
helping after death
parenting
stages of dying process
Family dynamics and relationships
Family dysfunction and abuse
Fecal impaction
Fecal incontinence
Federal Old Age Insurance Law
Femoral pulse
Ferrous supplements, food and drug interactions with
Fiber
Fibric acid derivatives
Fidelity
Financial limitations
Financial services
Finger-prick method
Fingers, physical assessment of
Fire hazards
First-generation (conventional/typical) agents
Fiscal constraints
Fish oil
Fitness programs
Flatulence
Flatus
Flavonoid
Fluid
body
and electrolyte imbalance
drug-related
intelligence
Fluoroquinolones
Folate, recommended intake of
Food
Forgiveness, spirituality
Foster care
Frailty
Fraud
Free radicals and lipofuscin theories
Fremitus
Frontotemporal dementia
Functional consequences theory
Functional incontinence
Funeral arrangement
Furosemide, food and drug interactions with
G
Gait disturbances
Garlic
Gastroesophageal reflux disease (GERD)
Gastrointestinal system
acute appendicitis
biliary tract disease
cancer of pancreas
cancer of stomach
cholelithiasis
chronic constipation
colorectal cancer
constipation
dental problems
diverticular disease
dry mouth (xerostomia)
dysphagia
effects of aging on
esophageal cancer
fecal impaction
fecal incontinence
flatulence
functions of
GERD
health promotion for
hiatal hernia
intestinal obstruction
oral health and frailty
oral health practices for older adults
peptic ulcer
selected
Gastrointestinal upset, drug-related
Gay
Genetic theories
Geriatric depression scale
Geriatric nursing
Gerontological nursing
advance directives
advance research
advanced practice
as advocate
ANA standards of practice
balance quality care
as caregiver
committing to dynamic process
competencies
connection with self
development of
educate caregivers
as educator
ethical dilemmas
ethics in
evidence-based practice
framework
functions of
future of
as healer
health care costs
holistic
information system of
as innovator
integrative care
journaling
landmarks in the growth of
laws governing
legal liability
legal risks in
legal safeguards
meditating
needs
new roles, development of
nursing care plan
optimal health and wholeness
positive health care practices
principles
processes
quality care
relationships
religious beliefs and practices
roles
self-care and nurturing ( See also Self-care and nurturing)
settings and roles
sharing life stories
spirituality
standards
strengthening and building connections
taking retreats
Gerotranscendence theories
Gingivitis
Ginkgo biloba
Glaucoma
acute
care and prevention of complications
chronic
older adult with open-angle glaucoma
Glibenclamide
Glomerulonephritis
Goiter
Grandparenting
Gratification
Gratitude, spirituality
Greek Orthodox, beliefs and practices, death related
Group homes
Guardianship
Guided imagery
Guillain-Barré syndrome
H
Hair
on extremities
nurtritional assessment
Hallux valgus. See Bunions
Hammer toe (digiti flexus)
Handicap
Harris–Benedict equation
Healer, nurse as
Healing
Healing art
Healing characteristics
availability
models of holism
presence
willingness to form connections
Healing touch (HT)
Health care
home
Health care costs, gerontological nursing
Health challenges-related needs
Health insurance
Health Insurance Portability and Accountability Act (HIPAA)
Health ministry and parish nurse programs
Health promotion
assessing problems
nutrients beneficial to vision
promoting hearing
promoting vision
Health promotion-related needs
Hearing, age-related changes in
Hearing aids. See also Vision and hearing
behind-the-ear model
in-the-ear model
Hearing deficits
hearing aids
patient care
Heart disease
diet and
in women
Heat and cold therapies
Height, measurement of
Helicobacter pylori infection
Hemianopsia
Hemiparesis
Hemiplegia
Hemoglobin A1c test (HbA1c)
Herbal medicine
Herb–drug interactions
Herbs, for pain management
Hereditary nonpolyposis colon cancer (HNPCC)
Hernia, perineal
Hiatal hernia
older adult with
High-density lipoprotein (HDL)
Hill–Burton Hospital Survey and Construction Act
Hinduism, beliefs and practices
Hip
range-of-motion
assessment of
exercises
Hispanic Americans
HIV infections, in black Americans
HIV-related dementia
Holism, models of
Holistic care
assessment of needs
case examples of
desire and decision to take action
gerontological care
healer role of nurse
health challenges-related needs
health promotion-related needs
knowledge, experience, and skills
nursing care plan
physical, mental, and socioeconomic abilities
requisites to meet needs
shared care plan
Homans’ sign
Home-delivered meals
Home health care
Home monitoring
Home shopping
Homeopathy
Honoring beliefs and practices, spirituality
Hope, spirituality
Hormone replacement therapy (HRT)
Hospice care
Hospital care
Hospitalization
quality of care in
risks of
Housing
Hydration. See Nutrition
Hydrotherapy
3-Hydroxy-3-methylglutaryl-coenzyme (HMG CoA)-reductase inhibitors
Hygiene, activities of daily living assessment and
Hypercalcemia, impaired cognition and
Hyperemia
Hyperglycemia
Hyperlipidemia
diagnosis
treatment
Hyperplasia, benign prostatic
Hypertension
Hyperthermia, impaired cognition and
Hyperthyroidism
goiter
symptoms
treatment
Hypnosis
Hypnotherapy
Hypnotics
Hypocalcemia, impaired cognition and
Hypoglycemia
Hypokalemia
Hypotension
Hypothermia, impaired cognition and
Hypothyroidism
symptoms
thyroid-stimulating hormone (TSH)
treatment
Hypoxia, impaired cognition and
I
Iatrogenic complications
Ibuprofen
Imagery
Immune system, age-related changes in
Immunosenescence
Impairment
Incidental hypothermia
Income
Incontinence
established
factors assessing
fecal
functional
Kegel exercises
mixed
neurogenic (reflex)
older adult with
overflow
stress
transient
urgency
Indigestion and food intolerance
Ineffective tissue perfusion, indications of
Infections
bacterial pneumonia
high risk
urinary tract infection
Influenza
Informed consent
Ingrown nails (onychocryptosis)
Injections
Botox
of embryonic tissue
intramuscular
Injury
Inner resources
Innovator, nurse as
Insomnia
Institutional care. See also Long-term care facilities
chronic illness
Instrumental activities of daily living (IADLs)
Insurance, health
Integumentary system
Intellectual or developmental disabilities, pain and
Intelligence, age-related changes in
Intestinal obstruction
Intimacy
Intramuscular injection
Invasion of privacy
Iodine, recommended intake of
Iron, recommended intake of
Ischemia
Islam (muslim), beliefs and practices
Isoniazid
J
Japanese Americans
Jehovah’s Witnesses, beliefs and practices
Jerking leg movements. See Restless leg syndrome
Jewish Americans
Jewish, death related beliefs and practices
Joint stiffness
Journal of Gerontological Nursing
Journaling, by nurse
Journaling, gerontological nursing
Judaism, beliefs and practices
Justice
K
Kegel exercises
Keratosis
Knee
range-of-motion
assessment of
exercises
Kosher diet
Kyphosis
L
Laboratory values, monitoring
Larceny
Latency
Lateral position
Laxatives
food interactions with
Learning, age-related changes in
Leg ulcer
Legal and tax services
Legal issues
advance directives
assault
battery
confidentiality
in death and dying
defamation of character
do not resuscitate orders
elder abuse
false imprisonment
fraud
invasion of privacy
larceny
malpractice
medications
negligence
patient competency
patient consent
restraints
staff supervision
telephone orders
Lentigo maligna melanoma
Lesbian
Lesbian, gay, bisexual, transgender, and queer (LGBTQ)
Letters, writing
Levodopa, food and drug interactions with
Lewy body dementia
Life expectancy
Life review
Life span
Life story
Life transitions
ageism
eliciting life stories
family roles/relationships, changes in
health and functioning, changes in
loss of spouse
mortality, awareness of
responding to
life review and life story
self-reflection
strengthening inner resources
retirement
loss of the work role
reduced income
shrinking social world
Light therapy
Lips, physical examination of
Long-term care facilities
assisted living communities
community-based and home health care
during COVID-19 pandemic
culture change movement
development of
Eden alternative
hierarchy of nursing home residents’ needs
holism and healing
hygiene
nursing home
admission
residents
selection
standards
nursing home residents
nursing roles and responsibilities
Loop diuretics
Love, spirituality
Low-density lipoprotein (LDL)
Lubricants
Lung abscess
Lung cancer
Lutheran, beliefs and practices
death related
M
Macroenvironment
Macular degeneration
Magnesium
Malfeasance
Malignancy, impaired cognition and
Malnutrition
Malpractice
reducing the risk of
Man
benign prostatic hyperplasia
erectile dysfunction
male
penis/testes/scrotum, tumors of
prostate cancer
testicular tumors
MAP (the Movement Advancement Project)
Massage
comfort
therapy
McGill Pain Questionnaire
Medicaid
Medical technology
Medicare
Medicare Advantage Prescription Drug Plan
Medications. See also Drug(s)
Meditation
concentrative
mindfulness
transcendental
Melanocytes
Melanoma
acral lentiginous
lentigo maligna
nodular
superficial spreading
Memory, age-related changes in
Mennonite, beliefs and practices
Menopause
age-related changes and sexual response
andropause
complementary and alternative approaches
Education Program
intimacy
patient education
self-acceptance
sexual behavior and roles
symptom management
Mental health disorders
aging and mental health
alcohol abuse/use
anxiety
behavioral problems
depression
signs and symptoms
suicide risk
treatment
managing behavioral problems
monitoring medications
nursing considerations for
in older adults
paranoia
positive self-concept
substance abuse
Meta-analysis
Metabolic syndrome
Methodist, beliefs and practices
Microenvironment
Midarm circumference
Mild cognitive impairment
Mineral oil, food and drug interactions with
Minerals, risks associated with excess intake of
Misconceptions
Misfeasance
Mixed incontinence
Mobility, activities of daily living assessment and
MOLST (Medical Orders for Life-Sustaining Treatments) forms
Mongolian spots
Mormons, beliefs and practices
death related
Mortality, awareness of
Musculoskeletal system
aging and risks to
bunions (hallux valgus)
calluses
corns
effects of aging on
effects of inactivity
exercise programs for older adults
fractures
gait disturbances
gout
hammer toe (digiti flexus)
health promotion
inactivity, prevention of
infections
ingrown nails (onychocryptosis)
mind–body connection
musculoskeletal function
nursing considerations for
nutrition
osteoarthritis
osteoporosis
pain management
physical exercise in all age groups
plantar fasciitis
podiatric conditions
preventing injury
promoting independence
reduced mobility
rheumatoid arthritis
selected conditions
self-care devices
Muslim, death related beliefs and practices
Muslims
Mutation accumulation theories
Mycobacterium tuberculosis
Myocardial infarction
N
Nails, condition of
National Institutes of Health Stroke Scale (NIHSS)
Nationality
Native Americans
Naturopathic medicine
Naturopathy
Nausea and vomiting
drug related
Neck
range-of-motion
assessment of
exercises
Necrosis
Negligence
Nervous system
cerebrovascular accidents
effects of aging on
indications of neurologic problems
intellectual performance
neurologic function
neurologic health promotion
nursing considerations for neurologic conditions
nursing problems
Parkinson’s disease
preventing injury
promoting independence
selected conditions
transient ischemic attacks
Neurogenic (reflex) incontinence
Neuropathic pain
Niacin
Nicotinic acid
Nightingale, Florence
Nitroglycerin
Nociceptive pain
Nocturia
Nocturnal myoclonus
Nodular melanoma
Nonfeasance
Nonmaleficence
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Nonstochastic theories
autoimmune reactions
environmental theories
genetic theories
neuroendocrine and neurochemical
nutrition theories
programmed/apoptosis
radiation theories
Nosocomial infections
Nothing to eat by mouth (NPO)
NSAIDs. See Nonsteroidal anti-inflammatory drugs (NSAIDs)
Numeric rating scale
Nursing care plan
Nursing homes
Nursing implications, age-related changes in
Nursing practice theories
Nursing problems
for chronic pain
for constipation
to death and dying
dehydration
for dermatologic problems
for gastrointestinal problems
for injury
to musculoskeletal problems
to neurologic problems
for reduced breathing capacity
for reduced mobility
for rest and sleep
for sexual dysfunction
for spiritual distress
for sleep deficiency
for surgery
Nutrition
aging and risks to
anorexia
caloric needs, quantity and quality of
for cardiovascular health
constipation
dehydration
dysphagia
excess intake
herb–drug interactions
indigestion and food intolerance
malnutrition
musculoskeletal system
nutritional status
in older adults
promotion of oral health
recommended dietary allowances
risks associated with
special needs of women
supplements
theories
threats to good nutrition
O
Odors
in aromatherapy
environmental
Older adults
advocate for
with cancer
with cerebrovascular accident
characteristics of
chronic conditions and
continuum of care for
with COPD
in decision making
discharge planning for
education of
exercise programs for
health insurance
health status
with heart failure
with hiatal hernia
history, view through
hospital care
hospitalization of
hydration needs of
inappropriate drugs to use in
income and employment
leading causes of death
life expectancy
living arrangements
marital status and living arrangements
nutritional needs of
nutritional status and hydration in
with open-angle glaucoma
oral health practices for
with osteoarthritis
pain in See (Pain)
population growth
prostate surgery in
qualitative study of
rest and sleep in See ( Sleep)
sex in
teaching
with urinary incontinence
Older Americans Act
Omega-3 fatty acids
Omnibus Budget Reconciliation Act (OBRA)
Onychomycosis
Opioid
Oral cavity
age related changes in
assessment of
physical examination of
Oral health
Ornish’s diet
Oropharyngeal dysphagia
Osmotics
Osteoarthritis
older adult with
Osteopathy
Osteoporosis
risk factors for
Ovaries, cancer of
Overflow incontinence
Oxyphenbutazone
P
Pain
acute
assessment
McGill Pain Questionnaire
numeric rating scale
visual analog scale
comforting
cycle
complementary therapies
control
dietary changes
management program
medication
neuropathic
nociceptive
in older adults
perception
persistent or chronic
in persons with cognitive impairments
somatic
types of
unrelieved
visceral
Pain management
Palliative care
Paranoia
Parenting
Parkinsonian gait
Parkinson’s disease
motion exercises
tension and frustration
Patient competency
Patient consent
Penicillins
Penis, tumors of
Pentazocine
Pentecostal, beliefs and practices
death related
Peptic ulcer
Perimenopause
Perineal herniation
Periodontal disease
Peripheral vascular disease
aneurysms
arteriosclerosis
diabetes, special problems associated with
managing problems associated with
varicose veins
venous thromboembolism
Persistent pain
Personal Emergency Response System (PERS)
Personality, age-related changes in
Pests
Pharmacodynamics
Pharmacokinetics
absorption
distribution
metabolism/detoxification/excretion
Pharynx, physical examination of
Phase advance
Phenobarbital, food and drug interactions with
Phenytoin, food and drug interactions with
Photoaging (solar elastosis)
Physical appearance, age-related changes in
Physical deconditioning
Physician selection, chronic illness
Physiological balance, gerontological nursing
Pioglitazone
Plantar fasciitis
Pneumonia
Podiatric conditions
POLST (Physician Orders for Life-Sustaining Treatments) forms
Polypharmacy
Poor nutritional intake
Popliteal pulse
Posterior tibial pulse
Postmenopause
Potassium
supplements, food/drug interactions with
Potassium-sparing diuretics
Power of attorney
Prayer
Preretirement phase
Presbycusis
Presbyesophagus
Presbyopia
Presbyterian, beliefs and practices
death related
Presence, healing characteristics
Pressure injury
deep tissue damage
hyperemia
ischemia
necrosis
PSST
stages
Pressure sore status tool (PSST)
Private law
Probenecid
Program of All-Inclusive Care for the Elderly (PACE)
Programmed theory of aging
Programmed/apoptosis
Progressive relaxation
Prone position
Protein, recommended intake of
Protestantism, beliefs and practices
Pruritus
Pseudodementia
Psychoactive drug
Psychological theories
Psychosocial factors, chronic illness
Public law
Pulmonary emboli
Q
Qigong
Quaker (Friends), beliefs and practices
Quality care, gerontological nursing
R
Race
Racism
Radial pulse
Radiation theories
Rapid eye movement (REM) stage sleep
Rational suicide
Reality orientation
Rectum, physical examination of
Regression
Regulations
Rehabilitation
activities of daily living
bowel and bladder training
functional assessment
living with disability
mental function maintenance and promotion
mobility aids and assistive technology
positioning
principles of
range-of-motion exercises
resources
Relativism
Relaxation, progressive
Religion
Religious beliefs and practices
of Buddhism
of Christian Science
of Eastern Orthodoxy
of Hinduism
of Islam (muslim)
of Jehovah’s Witnesses
of Judaism
of Mormons
of Protestantism
of Roman Catholicism
of Unitarian
Reminiscence
Renal calculi
Renal function, decreased impaired cognition and
Reproductive system
cancer screenings, among middle-aged African American Women
effects of aging
female
breast cancer
cervical cancer
cervix, problems of
dyspareunia
endometrial cancer
ovaries, cancer of
perineal herniation
problems of
vaginal cancer
vaginitis
vulva, infections and tumors of
male
benign prostatic hyperplasia
penis/testes/scrotum, tumors of
problems of
prostate cancer
recovering from prostate surgery
nursing problems associated with
testicular tumors
Respiratory distress
Respiratory system
aging and risks to
COPD
decreased, impaired cognition and
effects of aging on
reduction in body fluid
upper airway passages
breathing exercises
environmental factors
immobility
smoking
influenza
lung abscess
lung cancer
nursing considerations
preventing complications
recognizing symptoms
oxygen administration, safe
complementary therapies
encouragement
postural drainage
productive coughing
self-care
pneumonia
reduced breathing capacity
Respite care
Respondeat superior
Rest. See also Sleep
Resting energy expenditure. See also Harris–Benedict equation
Restless leg syndrome
Restorative care. See also Rehabilitation
Restraints
Retirement
loss of the work role
phases of
disenchantment
preretirement
reorientation
retirement routine
termination of
reduced income
Reverse immigration
Rheumatoid arthritis
Riboflavin
Rolfing
Roman Catholicism, beliefs and practices
Rosiglitazone
Russian Orthodox, death related beliefs and practices
S
Safety
aging and risks to
bathroom hazards
clothing
colors
crime avoidance an
environmental impact
falls and
fire hazards
floor coverings
functional impairment
furniture
hydration and nutrition risks reduction
impact of aging on
infection, prevention of
lighting
Maslow’s Hierarchy, environmental needs
medications
mobility limitations
monitoring body temperature
noise control
physical limitations
problems, early detection of
promoting safe driving
psychosocial considerations
restraints and
risk reduction
scents
sensory deficits
sensory stimulation
temperature
SAGE (Services and Advocacy for Gay, Lesbian, Bisexual, and
Transgender Elders)
Salvation Army, beliefs and practices
Sandwich generation
Sarcopenia
Scientologist, beliefs and practices, death related
Scope and Standards of Gerontological Nursing
Scrotum, tumors of
Seborrheic keratosis
Second-generation (atypical) agents
Sedatives
Selenium
Self-acceptance
Self-care and nurturing
Self-reflection, life transitions
journaling
through art
writing letters and e-mails
Senoras
Sensory health promotion
assessing problems
promoting hearing
promoting vision
Sensory limitations
Sensory organs, age-related changes in
Seventh Day Adventist, beliefs and practices
death related
Sexual behavior and roles
Sexual dysfunction
aging and risks
causative or contributing factors
cognitive impairment
medical conditions
medication adverse effects
psychological barriers
sexual health
unavailability of a partner
Sexual response, age-related changes and
Sexuality and intimacy
barriers to sexual activity
menopause
promoting healthy sexual function
Shared care plan
Short Michigan Alcohol Screening Test-Geriatric Version (SMAST-G)
Shoulder
range-of-motion
assessment of
exercises
Sildenafil citrate (Viagra)
Sjögren’s syndrome
Skin cancer
acral lentiginous melanoma
lentigo maligna melanoma
melanoma
nodular melanoma
superficial spreading melanoma
Skin health
alternative therapies
effects of aging on
nursing problem
skin cancer
skin status
keratosis
melanocytes
pressure injury
promoting normalcy
pruritus
seborrheic keratosis
skin cancer
vascular lesions, stasis ulcers
Skin, nurtritional assessment
Skin status
mongolian spots
turgor
Skipped-generation household
Sleep
activity and rest schedules
aging and risks to
apnea
Circadian sleep-wake cycles
deficiency
disturbances
drugs affecting
efficiency and quality
environment
factors affecting
food and supplements
insomnia
latency
medical conditions affecting
nocturnal myoclonus
nonpharmacologic measures
in older adults
pain control
pharmacologic measures
restless leg syndrome
and self-rated health in aging workforce
stages
stress management
Smart lifestyle choices, chronic illness
SMAST-G (Short Michigan Alcohol Screening Test-Geriatric Version)
Smell, age-related changes in
Smoking
Sobadoras
Social Security
Social support and activities
Sociologic theories
disengagement
Solar elastosis
Solitude, spirituality
Somatic death
Somatic pain
Sound therapy
SPF (sun protection factor)
Spiritual distress
Spiritual needs
closeness and trust
dignity
expression of faith
forgiveness
gratitude
honoring beliefs and practices
hope
love
meaning and purpose
solitude
transcendence
Spiritual well-being, lack of
Spirituality
addressing spiritual need
assessment for
assisting in discovering meaning
gerontological nursing
hope
importance of spiritual care
praying with and for
religious practices
spiritual needs
Spironolactone, food and drug interactions with
Spouse, loss of
Staff supervision
Standard
of care
Standards for Geriatric Nursing Practice
Stasis ulcers
Statins
Status of vessels
Stimulants
Stool softeners
Stool specimen, physical examination of
Stress, emotional, impaired cognition and
Stress incontinence
Stress management
Stress management practices
Stroke
Subacute care
Subculture theories
Substance abuse
Sulfisoxazole
Sun protection factor (SPF)
Sundowner syndrome
Superficial spreading melanoma
Supine position
Supplemental Security Income (SSI)
Support group, chronic illness
Surgical care
complications
nursing problems
operative care considerations
postoperative care considerations
preoperative care considerations
risks in
T
Tadalafil (Cialis)
Tai chi
Taste, age-related changes in
Telephone orders
Telephone reassurance
Temporal pulse
Testicular tumors
“The Old Nurse”
Theophylline, food and drug interactions with
Therapeutic touch (TT)
Thermoregulation, age-related changes in
Thiamin, recommended intake of
Thiazides
food interactions with
Thioridazine, food and drug interactions with
Thrombolytic therapy
Thumb, range of motion exercise
assessment of
exercises
Thyroid-stimulating hormone (TSH)
Tinea pedis
Toes
range of motion of
assessment of
exercises
Toileting, activities of daily living assessment and
Tongue, physical examination of
Touch, age-related changes in
Touch therapies, comfort
Toxic substances, impaired cognition and
Transcendence, spirituality and
Transgender
Transient incontinence
Transient ischemic attack (TIA)
Transportation
Trauma
and toxins
Tricyclic antidepressants, drug interactions with
Triglyceride monitoring
Turgor
U
Ulnar pulse
Unitarian, beliefs and practices
death related
Unrelieved pain
Urgency incontinence
Urinary elimination
with aging and urinary problems
bladder cancer
effects of aging
function of
general nursing considerations
glomerulonephritis
incontinence
older adult with
renal calculi
urinary tract infection
Urinary system, age-related changes in
Urinary tract infection
Urticaria
Utilitarianism
V
Vaccination
Vaginal cancer
Vaginitis
Vardenafil (Levitra)
Vascular dementia
Vascular lesions
stasis ulcers
Veracity
Vertigo
Visceral pain
Vision, age-related changes in
Vision and hearing
effects of aging
hearing deficits
hearing aids
patient care
hospital experience of older adults
nursing considerations
sensory health promotion
assessing problems
promoting hearing
promoting vision
visual deficits
cataracts
corneal ulcer
detached retina
glaucoma
macular degeneration
Visual analog scale
Visual deficits
cataracts
corneal ulcer
detached retina
glaucoma
macular degeneration
Vital capacity
Vitamin B6
Vitamin B12
Vitamin C
Vitamins
risks associated with excess intake of
Volunteer work
Vulva, infections and tumors of
W
Walkers
Warfarin, food and drug interactions with
Wear and tear theories
Wernicke’s encephalopathy
Wheelchairs
Widowhood
WOCN (wound, ostomy and continence nurses society)
Women
breast cancer
cervical cancer
cervix, problems of
dyspareunia
endometrial cancer
ovaries, cancer of
perineal herniation
problems of
vaginal cancer
vaginitis
vulva, infections and tumors of
Wound
dehiscence
evisceration
Wound, ostomy and continence nurses society (WOCN)
Wrist
range of motion of
assessment of
exercises
Writing letters
X
Xerostomia (dry mouth)
Y
Yoga
older adults
Z
Zinc

Gerontological Nursing, 10e - Charlotte Eliopoulos

Uploaded by

Copyright:

Available Formats

Gerontological Nursing, 10e - Charlotte Eliopoulos

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Gerontological Nursing, 10e - Charlotte Eliopoulos

Uploaded by

Copyright:

Available Formats

Gerontological Nursing

Copyright © 2022 Wolters Kluwer

Cataloging-in-Publication Data available on request from the Publisher

Moreen Areh, RN, BSN, MSN, FNP, DNP

Sherry A. Greenberg, PhD, RN, GNP-BC, FGSA, FAANP,

Margaret Huryk, DNP, APN-C

Linda Turchin, MSN, RN, CNE

Mary Beaudry, DNP, MSNed, MA, RN

Meg Bourbonniere, PhD, RN

Sarah Gilbert, PhD, RN, GCNS-BC

Elsie A. Jolade, DNP, FNP-BC, ACNS, EdM, APRN, CCRN

Joy D. Kimbrell, DNP, RN, CNE

Miranda Knapp, DNP, APRN, AGCNS-BC

Debra Parker, DNP, RN

Ashley J. Polzer, MSN, RN

Leah Richardson, PhD, MSN, RN

NEW! Next Generation NCLEX-Style Case Studies and Questions

Resources for Instructors

Resources for Students

Online Appendix A, Next Generation NCLEX-Style Case Studies

Engaging course content provides a variety of learning tools to engage

Unmatched support includes training coaches, product trainers, and nursing

UNIT 1 THE AGING EXPERIENCE

UNIT 3 HEALTH PROMOTION

UNIT 4 GERIATRIC CARE

UNIT 5 SETTINGS AND SPECIAL ISSUES IN

UNIT 1 THE AGING EXPERIENCE

UNIT 3 HEALTH PROMOTION

UNIT 5 SETTINGS AND SPECIAL ISSUES IN

CASE STUDIES IN THIS BOOK

3. Discuss projected changes in future generations of older people and the

VIEWS OF OLDER ADULTS

TABLE 1-1 Publicly Supported Programs of Benefit to Older

CHARACTERISTICS OF THE OLDER

TABLE 1-2 Differences in Life Expectancy at Birth by Race,

Although life expectancy has increased, it still differs by race and

Marital Status and Living Arrangements

Income and Employment

BOX 1-1 Social Security and Supplemental

Although the percentage of the total population that older adults

CONSIDER THIS CASE

4. What are the implications to society of people like the

BOX 1-2 Ten Leading Chronic Conditions

Source: National Council on Aging. Retrieved January 3, 2020 from

BOX 1-3 Leading Causes of Death for Persons

Concept Mastery Alert

Despite the advances in the health status of the older population,

Impact of the Baby Boomers

Some assumptions can be made concerning the baby boomer population

Provision of and Payment for Services

TABLE 1-3 Average Length of Hospital Stay

Less than 5% of the older population is in a nursing home, assisted

BRINGING RESEARCH TO LIFE

The Impact of an Aging Population in the

CRITICAL THINKING EXERCISES

1. Discuss the change in focus regarding learning about factors

FIGURE 2-1 Aging is a highly individualized process,

To explain biological aging, theorists have explored many factors, both

Free Radicals and Lipofuscin Theories