Gerontological Nursing

SECTION 1
CRITICAL THINKING
CHAPTER 1
Introduction to Gerontological Nursing
Gerontology – is the broad term used to
define the study of aging and/or the
aged. This includes the biopsychosocial
aspects of aging.
Older Age Group Division:
1. Young Old – (Ages 65-74)
2. Middle Old – (75-84)
3. Old old – (85 and up)
Geriatrics – is often used as generic term

relating to the aged, but specifically
refers to medical care of the aged.
Types of Gerontology
1. Social Gerontology – is concerned

mainly with the social aspects of
aging versus the biological or
psychological.
• Geropsychology– is a branch of
psychology concerned with helping
older persons and their families
maintain well-being, overcome
problems, and achieve maximum
potential during later life.
Geropharmocology – is the study of
pharmocology as it relates to older
adults.
2. Financial Gerontology – is another
emerging subfield that combines
knowledge of financial planning ang
services with a special expertise in the
needs of older adults. Cutler (2004)
defines financial gerontology as “the
intellectual intersection of two fields,
gerontology and finance, each of which
has practitioner and academic
components”
3. Gerontological Rehabilitation Nursing–
combines expertise in gerontological
nursing with rehabilitation concepts and
practice.
4. Gerontological Nursing – falls within

the discipline of nursing and the scope
of nursing practice..
Roles of the Gerontological Nurse
1. Provider of Care
2. Teacher
3. Manager
4. Advocate
5. Research Consumer
CERTIFICATION
To provide competent, current care to
elders, nurses need to have
gerontological nursing content in their
basic undergraduate nursing curricula
and are encouraged to become certified
in gerontological nursing.
Nurse Certification – is a formal process

by which a certifying agency validates a
nurse’s knowledge, skills, and
competencies through a written
examination in a specialty area of
practice.
Levels of Certification
1. Generalist Level – the generalist in
gerontological nursing has completed
a basic entry-level program in nursing
which can be a diploma in nursing, or
an associate or bachelor of science
degree in nursing.
2. Advanced Certification – the ANCC
offers 2 separate advanced practice
certification exams in gerontological
nursing.
• Clinical Specialist in Gerontological
Nursing
• Gerontological Nurse Practioner

Both must be a Master’s Degree in
Nursing
Roles of Gerontological Certified Nurses
• Assess, manage, and deliver health
care that meets the needs of older
adults.
• Evaluate the effectiveness of their
care.
• Identify the strengths and limitations
of their patients.
• Maximize patient independence.
• Involve patients and family members.
(American Nurses Credentialing Center,
ANCC, 2008)
Reasons to be Certified Gerontological
Nurses
• Experience a high degree of

professional accomplishment and
satisfaction
• Demonstrate a commitment to their
profession.
• Providehigher quality of care to older
adults.
• Act as resources for other nurses and
interdisciplinary team members.
• Demonstrate evidence-based
gerontological nursing care.
• Create the potential for higher salaries
• Are actively recruited for employment
at nursing faculty, hospitals, long
term care facilities, acute rehab, and
in community health agencies.
Core Competencies – Skills, Knowledge

and Attitude
Competencies Necessary for Nurses to
Provide High Quality Care to Older
Adults and Their Families
1. Recognize one’s own and others’

attitudes, values, and expectations
about aging and their impact on care
of older adults and their families.
2. Adopt the concept of individualized
care as the standard of practice with
older adults.
3. Communicate effectively,
respectfully, and compassionately
with older adults and their families.
4. Recognize that sensation and
perception in older adults are
mediated by functional, physical,
cognitive, psychological, and social
changes common in old age.
5. Incorporate into daily practice valid
and reliable tools to assess the
functional, physical, cognitive,
psychological, social and spiritual
status of older adults.
6. Assess older adults’ living
environment with special awareness
of the functional, physical, cognitive,
psychological, and social changes
common in old age.
7. Analyze the effectiveness of
community resources in assisting
older adults and their families to
retain personal goals, maximize
function, maintain independence, and
live in the least restrictive
environment.
8. Assess family knowledge of skills
necessary to deliver care to older
adults.
9. Adat technical skills to meet the
functional, physical, cognitive,
psychological, social, and endurance
capacities of older adults.
10. Individualize care and prevent
morbidity and mortality associated
with the use of physical and chemical
restraints in older adults.
11. Prevent or reduce common risk
factors that contribute to functional
decline, impaired quality of life, and
excess disability in older adults.
12.Establish and follow standards of
care to recognize and report elder
mistreatment.
13.Apply evidence-based standards to
screen, immunize, and promote
healthy activities in older adults.
13. Apply evidence-based standards to
screen, immunize, and promote
healthy activities in older adults.
14. Recognize and manage geriatric
syndromes common to older adults.
15. Recognize the complex interaction
of acute and chronic co-morbid
conditions common to older adults.
16. Use technology to enhance older
adults’ function, independence, and
safety.
17. Facilitate communication as older
adults transition across and between
home, hospital, and nursing home,
with a particular focus on the use of
18. Assist older adults, families, and
caregivers to understand and balance
“everyday” autonomy and safety
decisions.
19. Apply ethical and legal principles to
the complex issues that arise in care
of older adults.
20. Appreciate the influence of
attitudes, roles, language, culture,
race, religion, gender, and lifestyle on
how families and assistive personnel
provide long-term care to older
adults.
21. Evaluate differing international
models of geriatric care.
22. Analyze the impact of an aging
society on the health care system.
23. evaluate the influence of payer
systems on access, availability, and
affordability of health care for older
adults.
24. Contrast the opportunities and
constraints of a supportive living
arranagement on the function and
independence of older adults and on
their families.
25. Recognize the benefits of
interdisciplinary team participation in
care of older adults.
26. Evaluate the utility of
complementary and integrative
health care practices on health
promotion and symptom
management for older adults.
27. Facilitate older adults’ active
participation in all aspects of their
own health care.
28. Involve, educate, and when
appropriate, supervise family,
friends, and assistive personnel in
implementing best practices for older
adults.
29. Ensure quality of care
commensurate with older adults’
30. Promote the desirability of quality
end-of-life care for older adults,
including pain and symptom
management, as essential, desirable,
and integral components of nursing
practice.
HISTORY OF GERONTOLOGICAL NURSING
1902 – American Journal of Nursing
published the first Geriatric Article by an
MD.
published the first Geriatric Article by an
RN.
considered Geriatric Nursing as a
1950 – First Geriatric Nursing Textbook
(Geriatric Nursing, Newton), published
1952 – First Geriatric Nursing Study
published in Nursing Research.
1961 – ANA recommends specialty
group for Geriatric Nurses
1962 – ANA holds first National Nursing
Meeting on Geriatric Nursing Practice
1966 – ANA forms a Geriatric Nursing
Division “First Gerontological Clinical
Nurse Specialist Master’s Program
begins at Duke University.
1968 – First RN (Gunter) presents at the
International Congress of Gerontology.
1970 – ANA creates the Standards of
of Practice for Geriatric Nursing.
1973 – ANA offers the first generalist
certification in gerontological nursing
(74 nurses certified).
1975 – First Nursing Journal for the Care
of Older Adults Published: Journal of
Gerontological Nursing by Slack, Inc.
1976 – ANA Geriatric Nursing Division
changes name to Gerontological Nursing
Division. ANA publishes Standards of
Gerontological Nursing.
1977 – KELLOGG Foundation funds
Geriatric Nurse Practioner Certificate
Education. First Gerontological Nursing
Track funded by the Division of Nursing
The University of Kansas.
1979 – First National Conference on
Gerontological Nursing sponsored by
the Journal of Gerontological Nursing.
1980 – AJN publishes Geriatric Nursing
Journal Education for Geriatric Nurses
by Gunter and Estes suggests curricula
for all levels of nursing education ANA
establishes Council of Long Term Care
Nurses.
1980 – First Robert Wood Johnson (RWJ)
Foundation grants for health-impaired
elders given (eight in the United
States).
1981 – First International Conference on
International Council of Nursing (Los
Angeles, California)
2008 – Geriatric Nursing Journal
Celebrates 30 years Journal of
Gerontological Nursing Research
emerges.
Attitudes Towards Aging and Older
Adults
Ageism – the negative attitudes toward

aging or older adults.
1. Provider of Care
2. Teacher
3. Manager
4. Advocate
5. Research Consumer
Places for the Gerontogical Nurse to

Care For
6. Acute Care Hospital
7. Acute Rehabilitation
8. Home Health Care
9. Long Term Care Facility
10.Skilled Nursing Facilities
11.Alzheimer’s Care
12.Hospice
Places for the Gerontogical Nurse
to Care For
8. Respite Care
9. Continuing Care Retirement
Community (CCRC)
10. Assisted Living
11.Foster Care or Group Homes
12.Green House Concept
13.Adult Daycare
AACN ESSENTIALS (1998)
Core Competencies
14.Critical Thinking
15.Communication
Core Competencies
3. Assessment
4. Technical Skills
Core Knowledge
5. Health promotion, risk reduction, and

disease prevention
6. Illness and disease management
7. Information and health care
technologies
8. Ethics
Core Knowledge
6. Global health care

7. Health care systems and policy
Role Development
8. Provider of Care
9. Designer/manager/Coordinator of care
10.Member of a profession
CHAPTER 2
The Aging Population
What is Aging?
• Ageing (British English) or aging
(American English) is the process of
becoming older. In the narrow sense,
the term refers to biological ageing
of human beings, animals and other
organisms. In the broader sense,
ageing can refer to single cells within
an organism or to the population of a
species.
The causes of ageing are unknown;
current theories are assigned to the
damage concept, whereby the
accumulation of externally induced
damage (such as DNA point
mutations) may cause biological
systems to fail, or to the programmed
ageing concept, whereby internal
processes (such as DNA telomere
shortening) may cause ageing.
CULTURAL FACTORS/ ETHNICITY
SUCH AS REGARD FOR
PERCEPTION OF HEALTH
American and European
• Cultural factors influencing the

mental health of American
• Language
• Level of acculturation
• Age
• Gender
• Occupational issues
• Family structure and
intergenerational issues
• Religious beliefs and spirituality
• Traditional beliefs about mental
health
• ELDERLY
• Whereas Americans emphasizes
independence as means to
maintain their self esteem and
to avoid becoming burdens to
their children, elderly Asians
look forward to having their
grown children care of them.
• Assessment:
• Practitioner awareness of individual
patient demography.
• The patient’s, beliefs about health and
mental health.
• Negotiation around acceptable diagnosis
and treatment.
• Use of the family support system to
increase adherence to treatment
regimens and to reduce barriers.
• Cultural factors, such as language, age,

gender, and other can influence the
mental health of Asians particularly
immigrant.
• Traditional adhering to native values.
• Social stigma, shame and saving
face of ten prevent Asians from
seeking behavioral health care.
• Asian patient are likely to express
psychological distress as physical
complaints and intergenerational.
EUROPEAN
European as higher status in
society and both has more contact
with European than Chinese elders
outside family.
• Cultural Factors or Ethnicity such
as regard for Elders, Perception
of Health
Background:
• In 2003, The Institute of Medicine
provided compelling evidence on lower
quality of health care received by
racial and ethnic minorities compared
to non-minorities including unequal
care for minority older persons
• Access to culturally appropriate

resources and programs on health
promotion and management of acute
and chronic health problems are
critical elements to improve care.
• Culture- the way of life of a
population, including shared
knowledge, beliefs, values, attitudes,
rules of behavior, language, skills,
and world view among members of a
given society.
• Ethnicity-the active expression of
culture.
• Geriatric-of or relating to geriatrics,
old age, or aged persons.
Ethnogeriatrics
• is a developing subspecialty in
geriatrics with an emphasis on
the intersect of knowledge from
the fields of aging, health, and
ethnicity
Assessment
• Demonstrating respect (deference) to older
patients in culturally appropriate ways helps
to establish a trusting relationship.
• greet older persons first
• use of informal conversation
• attitude of sincere concern
• Acknowledge the importance of ethnicity
Assessment
Facilitating Communication Selecting
Interpreters
• trained interpreters should be used
• Use of family members, especially
young children, as interpreters is
strongly discouraged
• Avoid using untrained interpreters.
• Explain to the patient why an
interpreter is needed
Assessment
Maximizing Verbal and Non-verbal
Communication
• Pace of Conversation
• Speak Slowly
• Physical Distance
• Eye Contact
• Emotional Expressiveness
• Body Movements
• Touch
• Modesty
African American Elderly
• There are approximately two million African
Americans age 65 or older in the U.S.,
representing about 8% of the African
American population.
• African American elders tend to have
significantly lower socioeconomic status than
do white elders
 possible reasons for the high poverty rate among
African American elders, including inadequate
education, discrimination in hiring and rates
of pay, work histories of low wage jobs, and high
unemployment resulting in lower Social
Security and private pension plan coverage.
African American Elderly
• African American elders tend to
perceive their health as more
problematic than do white
elders.
• Health
• Much of this differential in health status can
be attributed to increased rates of poverty
among African American elders, lack of
adequate health care throughout life, and a
greater likelihood of working at manual,
physically debilitating jobs. Moreover, older
African Americans are less likely than white
elders to have health insurance
• Reasons for these differences include

discrimination in referrals to long term care
services, potential social isolation,
geographical discrimination in nursing homes
and shorter life expectancies
• Family Roles
• Some of the African American family's
strengths include: strong parent child
and sibling ties; greater likelihood of
providing economic and social support
to extended family members; large
proportions of family members residing
within the same neighborhood or area;
care for ill and dependent family
members; strong work orientation;
adaptable family roles; strong religious
orientation;
Nursing Diagnosis Related to
Wellness and
Chronic Illness
A. PSYCHOSOCIAL FUNCTION
 Self-Esteem Disturbances (Risk for)
A state in which an individual who previously

had (+) self esteem experiences negative
feelings about self in response to an event.
Related factors: Internalization of ageist

attitude ,loss of roles/financial security, a need
for change to a more dependent living
arrangement and chronic illness that affect
one’s ability and role identities.
 Powerlessness (Risk for)
A state in which an individual / group perceives

a lack of personal control over certain events
which affects outlook, goals, and lifestyle.
Example: Loss of the ability to drive a car, lack of

involvement in decision making
 Impaired Adjustment
A state in which an individual is unable to modify

his/her lifestyle/behavior in a manner consistent
with a change of health status
Example: Older adult who is driving unsafely because
of cognitive / other functional deficit but does not
refuses driving.
 Ineffective Coping
A state in which a individual experiences/at risk of

experiencing inability to manage internal/stressor
adequately because of inadequate resources.
 Social Isolation
A state in which an individual/group experiences or

perceives a need or desire for increase involvement
with others but is unable to make that contact.
 Impaired Social Interaction
A state in which an individual experiences or at risk of

experiencing negative, insufficient or unsatisfactory
responses from interaction.
 Spiritual Distress (Risk for)

 Impaired Religiosity (Risk For)
 Readiness for Enhance Spiritual Well-Being
Ability to experience and integrate meaning and purpose

in life through connectedness with self, others, art,
music, literature, nature or power greater than oneself.
WELLNESS NURSING DIAGNOSIS
 Readiness for Enhanced Coping

 Readiness for Enhanced Self Concept
B. COGNITIVE FUNCTION
 Health- Seeking Behaviors

A state in which an individual with stable
health actively seeks ways to alter personal
health habits
 Readiness for Enhanced Knowledge
C. AFFECTIVE FUNCTION
 Ineffective Coping
Helplessness
Chronic Low Self-Esteem
Powerlessness
Risk for Imbalance Nutrition
 Readiness for Enhanced Coping
D. CARDIOVASCULAR FUNCTION
 Activity Intolerance
 Risk for Aspiration
 Self –Care Deficit
Disturbed Body Image
Disturbed Sensory Perception
 Sexual Dysfunction
E. MUSCULOSKELETAL FUNCTION
Anxiety
 Risk for fall
Risk for injury
 Impaired Physical Mobility
 Decrease cardiac output
 Knowledge deficit
RESPIRATORY FUNCTION
 Ineffective Breathing Pattern

A status in which an individual experiences
an actual or potential loss of ventilation
related to an altered breathing pattern.
Risk for Infection
Ineffective Health Maintenance

 Readiness for Enhanced Immunization
Status
INTEGUMENTARY FUNCTION
 Impaired Skin Integrity(Risk for)
A state in which individual experiences or at

risk for altered epidermal or dermis
breakdown.
 Ineffective Health Maintenance
A state in which an individual or group

experiences or at risk experiencing a
disruption of health because of an
unhealthy lifestyle or lack knowledge to
manage the condition.
 Readiness for Enhance Knowledge: Skin Care
F. VISION FUNCTION
 Powerlessness
 Disturbed Body Image
 Disturbed Sensory Perception
 Impaired Skin Integrity
 Disturbed Sleep Pattern
 Impaired Social Interaction
HEARING FUNCTION
 Disturbed Sensory Perception: Auditory
A state in which individual experiences or at

risk of experiencing a change in the
amount, pattern, or interpretation of
incoming stimuli.
 Impaired Communication
A state in which individual has a difficulty in
exchanging thoughts, ideas, wants, or
needs with others.
 Risk for injury

Impaired Communication
A state in which individual has a difficulty
in exchanging thoughts, ideas, wants, or
needs with others.
 Risk for injury

 Readiness for Enhanced Communication
G. GENITOURINARY FUNCTION
 Ineffective Sexuality Pattern

A state in which an individual is experiencing or
at risk of experiencing a change in sexual
health.
 Readiness for Enhanced Knowledge:

Sexual Functioning
Diabetes
Type 1
Family History
Environmental
Factors
The presence of
damaging
immune system
cells
Dietary Factors
Type 2
Weight
Diet
Inactivity
Family History
Race
Age
Obesity/ overweight
Gestational Diabetes
Polycystic ovary syndrome
High blood pressure
Gestational Diabetes
Age
Family or personal history
Weight
Race
Cancer
Smoking
Diet and obesity
Sedentary Lifestyle
Occupation exposure
Family history
Viruses
Perinatal Factors/ Growth
Alcohol
Pollution
UV Radiation
Drugs and medical procedures
Salts, Food Additives and Contaminants
Dementia
Non-modifiable
Age
Family History Modifiable
Down Syndrome Heavy alcohol use
Gender Atherosclerosis
Blood pressure
Smoking
Stroke
Non-modifiable Modifiable
Age Hypertension
Gender Cardiac disease
Race Cigarette smoking
Ethnicity Alcohol
Heredity Illicit Drug Use
Lifestyle Factors
Transient Ischemic Attack
Migraine
PATTERNS OF ILLNESS
OF THE OLDER
PERSONS
• The issue influencing the
presentation of illness in some older
persons is an altered pattern or
distribution of illness. Some
conditions such as hip fracture,
parkinson’s disease, or polymyalgia
rheumatica are virtually confined to
the later stages of life.
• Some disease processes are more
prevalent in old age.
 Cardiovascular disorders
 Malignancy
 Malnutrition
 Myxedema
 Tuberculosis
• Some disease processes are more
prevalent in old age.
 Cardiovascular disorders
 Malignancy
 Malnutrition
 Myxedema
 Tuberculosis
Definition
• Dementia isn't a specific disease. Instead,
dementia describes a group of symptoms
affecting memory, thinking and social abilities
severely enough to interfere with daily
functioning.
• Dementia indicates problems with at least two
brain functions, such as memory loss and
impaired judgment or language, and the
inability to perform some daily activities.
Pathophysiology of Dementia
Dementia is a symptom of a variety of specific structural
brain diseases as well as several system degenerations.
Alzheimer’s disease presently is the commonest cause in
the developed world, causing a cortical-subcortical
degeneration of ascending cholinergic neurons and large
pyramidal cells in the cerebral cortex. Clinically, the
disease reflects predominantly deterioration of function
in the association cortex. Pharmacologically and
pathologically, abnormalities are more diffuse and extend
into sensorimotor cortical areas as well.
Dementia • Dementia symptoms vary depending
on the cause, but common signs and
Symptoms symptoms include:
• Cognitive changes
• Memory loss
• Difficulty communicating or finding
words
• Difficulty with complex tasks
• Difficulty with planning and
organizing
• Difficulty with coordination and
motor functions
• Problems with disorientation, such as
getting lost
Types of Dementia
Assessment
• Formal cognitive assessment
• A more detailed assessment of memory is
necessary and performed by using several specific
bedside cognitive tests. The role and method of
using such tests has been covered in a previous
supplement. During a thorough cognitive
assessment it is useful to examine the following:
• Orientation—in time and place
• Attention—for example, serial sevens, months of
the year or WORLD backwards
• Memory—for example, address recall, name of
prime minister, etc
• Language—for example, naming of items, reading,
writing, comprehension, repetition
• Executive function—for example, letter and
category fluency
• Praxis—for example, alternating hand
movements, imitation of gestures
• Visuospatial function—for example, drawing a
clock face, overlapping pentagons.
Medical Treatment
• Cholinesterase inhibitors: Tacrine (Cognex), donepezil (Aricept),
rivastigmine (Exelon), galantamine/galanthamine (Razadyne),
memantine (Namenda)
• Antidepressants/anxiolytics: Fluoxetine (Prozac), sertraline (Zoloft),

paroxetine (Paxil), citalopram (Celexa)
• Antipsychotics: Haloperidol (Haldol), risperidone (Risperdal),

quetiapine (Seroquel), olanzapine (Zyprexa), ziprasidone (Geodon)
• Anticonvulsants: Valproic acid (Depakote), carbamazepine

(Tegretol) gabapentin (Neurontin), lamotrigine (Lamictal)
• Stimulants: Methylphenidate (Ritalin)

Surgical Treatment
• No accepted surgical treatment can manage
dementia. Surgery is reserved for specific
conditions underlying dementia that might
improve the condition, such as removal of a
brain tumor or drainage of excess
cerebrospinal fluid.
Dementia Therapy
• Occupational therapy may help persons with

dementia with activities of daily living such as
feeding oneself. Physical therapy may improve
mobility by teaching patients to use canes or
walkers properly and showing them how to get in
and out of chairs or beds. Music and art activities
may be soothing and rewarding for some people
with dementia. Respite care, having a person with
dementia go temporarily to a nursing home, is
another important source of help for family
caregivers.
Nursing Management
• Ensure safe environment, by providing enough
lighting in the room and in the vicinity.
•Let the client wear an identification tag and
ensure that the client does not leave the
premises (wandering)
• Assist client in his ADLs while at the same time
providing some independence depending on
client’s abilities
Nursing Management
• Remind the patient to eat nutritious foods and
to drink enough fluids/ to take his medicines.
• Speak in a slow paced manner, considering
client’s limitations or abilities
• Anticipate what the client is trying to
say/Provide word or respond to
thought/feeling
• Provide activities in daytime
Behavioral Management
• Educate client, family members, and care giver
of his condition and the important things that
needs to be addressed like his memory loss,
impairments in communication, some
psychiatric symptoms, and personality changes.
• Talk with the client about recent events
• Avoid frequent changes in arrangements in
furniture etc. to minimize disorientation
• Find things and replace or hand to the client
without focusing on the forgetfulness
• Allow performance of skills as long as safe
• Maintain familiar social, physical, mental, and work
activities
• Provide emotional support and be tolerant to his
sentences/words and respond like it is the first time
stated or heard
• Provide objects that would make client recall of and
relate with, like pictures, significant objects, or even
his name by putting his name in his room
• Avoid stressful situations
Issues and Trends
• Acc to WHO, nearly 35.6 million people live with dementia worldwide. This
number is expected to double by 2030 (65.7 million) and more than triple by
2050 (115.4 million)
• Dementia affects people in all countries, with more than half (58%) living in
middle-income countries. By 2050, this is likely to rise to more than 70%.
• Treating and caring for people with dementia currently costs the world more
than US$ 604 billion per year.
• Lack of diagnosis is a major problem. Even in high-income countries, only one

fifth to one half of cases of dementia are routinely recognized. When a diagnosis
is made, it often comes at a relatively late stage of the disease.
• Only eight countries worldwide currently have national programmes in place to
address dementia
• World Health Organization (WHO) and Alzheimer's Disease International,
recommends that programmes focus on improving early diagnosis; raising
public awareness about the disease and reducing stigma; and providing better
care and more support to caregivers.
CHAPTER 3
Theories of Aging
The Damage or Error Theory include:
Wear and tear theory

where vital parts in our cells and tissues wear out
resulting in ageing.
Rate of living theory
that supports the theory that the greater an
organism's rate of oxygen basal, metabolism, the
shorter its life span.
Cross-linking theory
according to which an accumulation of cross-linked
proteins damages cells and tissues, slowing
down bodily processes and thus result in ageing.
Free radicals theory
which proposes that superoxide and other
free radicals cause damage to the
macromolecular components of the cell,
giving rise to accumulated damage
causing cells, and eventually organs, to
stop functioning.
The Membrane Theory of Aging

According to this theory it is the age-related
changes of the cells ability to transfer
chemicals, heat and electrical processes
that impair it.
The Cross-Linking Theory
The Cross-Linking Theory of Aging is
also referred to as the Glycosylation
Theory of Aging. In this theory it is
the binding of glucose (simple
sugars) to protein, (a process that
occurs under the presence of
oxygen) that causes various
problems.
Once this binding has occurred the
protein becomes impaired and is
unable to perform as efficiently. Living
a longer life is going to lead to the
increased possibility of oxygen
meeting glucose and protein and
known cross-linking disorders include
senile cataract and the appearance of
tough, leathery and yellow skin.
PSYCHOSOCIAL THEORIES OF AGING
Sociological Theories of Aging
1. Activity Theory – is another theory that
describes the psychosocial aging
process. Activity theory emphasizes the
importance of ongoing social activity.
2. Disengagement Theory – the emphasis
of this theory places on social
withdrawal has been challenged by
other theorists who argue that a key
element of life satisfaction among older
adults appears to be engagement in
meaningful relationships and activities.
It refers to an inevitable process in
between a person and other members of
society are severed & those remaining are
altered in quality.
3. Subculture Theory – Views older adults
as unique subculture within society
formed as a defensive response to
society’s negative attitudes and the
loss of status that accompanies aging.
4. Continuity Theory – also known as
development theory, suggest that
personality is well developed by the
time one reaches old age and tends to
remain consistent across the life span.
3. Subculture Theory – Views older adults
as unique subculture within society
formed as a defensive response to
society’s negative attitudes and the
loss of status that accompanies aging.
4. Continuity Theory – also known as
development theory, suggest that
personality is well developed by the
time one reaches old age and tends to
remain consistent across the life span.
5. Age Stratification Theory – Recognizing
that aging and society are interralated
and cause reciprocal changes to
individuals, age group cohorts, and
society.
6. Person-Environment-Fit Theory –
introduced functional competence in
relationship to the environment as a
central theme. It is affected by multiple
intrapersonal conditions such as:
a. Ego
b.Strength
c. Motor skills
d. Biologic health
e. Cognitive capacity
f. Sensori-perceptual capacity
g. External condition
7. Gerotranscendence Theory –
Tornstam’s theory, proposes that aging
individuals undergo a cognitive
transformation from a materialistic,
rational perspective toward oneness
with the universe.
PSYCHOLOGICAL THEORIES OF AGING
1. Human Needs Theory – it was

developed by Maslow in 1954. He
surmised that a hierarchy of five
needs motivates human behavior:
a. psychologic
b. safety and security
c. love and belonging
d. self-esteem
e. self-actualization
2. Theory of Individualism – Jung’s

theory in 1960 that proposes a life span
view of personality development rather
than attainment of basic needs. Jung
defines personality as being composed
of an ego or self-identity with a
personal and collective
unconsciousness.
Personal unconsciousness – is the
private feelings and perceptions
surrounding significant persons or life
events.
3. Stages of Personality Development

Theory – according to Erikson in 1963,
personality develops in eight
sequential stages that have a
corresponding life task that one may
succeed at or fail to accomplish.
4. Life-Course (Life Span Development)
Paradigm – the central concepts of this
blend key elements in psychological
theories such as:
a. Life stages
b. tasks
c. Personality development with

sociological concepts such as:
• Role behavior
• Interrelationship between individuals
and society
5. Selective Optimization with
Compensatory Theory – Baltes’ 1987
theory of successful aging emerged
from his study of psychological
processes across the life span and
individual. He asserts that individuals
learn to cope with the
functional losses of aging through

processes of:
a. Selection
b. Optimization
c. Compensation
BIOLOGICAL THEORIES OF AGING

A. Stochastic Theories – studies of
animals reflect that the effects of
aging are primarily due to:
a. Genetic defects
b. Development environment
c. Inborn aging process
1. Free Radical Theory – oxidative free
radical theory postulates that aging
is due to oxidative metabolism and
the effects of free radicals, which are
the end products of oxidative
metabolism. Free radicals are
produced when the body uses
oxygen, such as with exercise.
Free Radicals – are chemical species

that arise from atoms as single
unpaired electrons. Free radical
molecule is unpaired so it is able to
enter reactions with other molecules,
especially along membranes and with
nucleic acids. Free radicals cause:
• Extensive cellular damage to DNA,
which can cause malignancy and
accelerated aging, due to oxidative
modification of proteins that impact
cell metabolism.
• Lipid oxidation that damages
phospholipids in cell membranes,
thus affecting membrane
permeability.
• DNA strand breaks and base
modifications that cause gene
modulation.
Strategies to assist in Delaying the
Mitochondrial Decay
•Decrease calories in order to lower
weight.
•Maintain a diet high in nutrients
using antioxidants.
Strategies to assist in Delaying the
Mitochondrial Decay
• Avoid inflammation
• Minimize accumulation of metals in the
body that can trigger free radical
reactions.
Lipofuscin – cellular debris rich in lipids
and proteins.
Exogenous Sources of Free Radicals
a. Tobacco smoke
b. Pesticides
c. Organic solvents
d. Radiation
e. Ozone
f. Selected medications
2. Orgel/Error Theory – The theory
suggest that over time, cells
accumulate errors in their DNA and RNA
protein synthesis that cause the cells
to die. Environmental agents and
randomly induced events can cause
error, with ultimate cellular changes. It
is well known that large amounts of x-
ray radiation cause chromosomal
abnormalities. The theory proposes
that aging would not occur if
destructive factors such as radiation
did not exist and cause “errors” such
as mutations and regulatory disorders.
Hayflick in 1996 does not support
this theory, and explains that all aged
cells do not have errant proteins, nor
are cells found with errant proteins old.
3. Wear and Tear Theory – over time,
cumulative changes occurring in cells
age and damage cellular metabolism.
An example is the cell’s inability to
repair damaged DNA, as in the aging
cell.
Cells that Cannot Be Replaced by
Wear and Tear
a. Heart muscle
b. Neurons
c. Striated muscle
d. Brain
Excessive wear and tear due to
exercising may accelerate aging by
causing increased free radical production,
which supports the idea that no one
theory of aging incorporates all the
causes of aging, but rather a combination
of factors is responsible.
4. Connective Tissue Theory – referred to
as cross-link theory, it proposes that, over
time, biochemical processes create
connections between structures not
normally connected. Several cross-
linkages occur rapidly between 30-50
years of age.
B. Non-stochastic Theories
Non-stochastic theory are founded on
a programmed perspective that is related
to genetics or one’s biological clock.
Goldsmith in 2004 suggests that aging is
more likely to be an evolved beneficial
Results from a complex structured
process and not a series of random
events.
1. Programmed Theory – as people age,
more of their cells start to decide
commit suicide or stop dividing. The
Hayflick Phenomenon or Human
Fibroblast Replicative Senescence
Model, suggests that cells divide until
they can no longer divide, whereupon
the cell’s infrastracture recognizes this
inability to further divide and triggers
Therefore it is thought that cells have
a finite doubling potential and become
unable to replicate after they have done
so a number of times. This theory of
programmed cell death is often alluded to
when the aging process is discussed.
Telemeres – are the most distal
appendages of the chromosome arms.
Telomerase – is an enzyme also called a
“Cellular Fountain of Youth” allows human
cells grown in the laboratory to continue
to replicate long past the time they
stop dividing. Normal human cells do
not have telomerase.
2. Gene/Biological Clock Theory – this
theory explains that each cell, or perhaps
the entire organism, has a genetically
programmed aging code that is stored in
the organism’s DNA. Slagboom and
associates in 2000 described this theory
as comprising genetic influences that
predict physical condition, occurrence of
disease, cause and age of death, and
other factors that contribute to longevity.
Melatonin – is secreted by the pineal
gland and is considered to be the
hormone linked to sleep and wake cycles
because there are large numbers of
melatonin receptors in the SCN.
2. Neuroendocrine Theory – describes a
change in hormone secretion, such as
with the releasing hormones of the
hypothalamus and the stimulating
hormones of the pituitary gland, which
manage the thyroid, parathyroid, and
adrenal glands, and how it influences the
aging process.
Major Hormones that are Involved in
Aging
• Estrogen decreases thinning of bones,
and when women age less estrogen is
produced by the ovaries.
• Growth Hormone is part of the process
that increases bone and muscle
strength. It stimulates the release of
insulin-like growth factor produced by
the liver.
• Melatonin is produced by the pineal
gland and is thought to be responsible
3. Immunologic/Autoimmune Theory was
proposed 40 years ago and descrtibes the
normal aging process of humans and
animals as being related to faulty
immunological function (Effros, 2004).
There is a decreased immune function in
the elderly. The thymus gland shrinks in
size and ability to function. Thymus
hormone levels are decreased at the age
of 30 and are undetectable by the age of
60 (Williams, 1995).
NURSING THEORIES OF AGING
1. Functional Consequences Theory – was
developed to provide a guiding
framework that would address older
adults with physical impairment.
2. Theory of Thriving – by Haight et al in
2002 is based on the concept of failure
to thrive and Bergland and Kirkevold’s
in 2001 application of thriving to the
experience of well-being among frail
elders living in nursing homes.
Effects of Aging
A number of characteristic ageing symptoms are
experienced by a majority or by a significant
proportion of humans during their lifetimes.
• Teenagers lose the young child's ability to hear
high-frequency sounds above 20 kHz.
• A continuous decline in cognitive processes
occurs after a peak performance in the mid-20s
age group.
• By age 30, wrinkles develop mainly due to
photoageing, particularly affecting sun-exposed
areas (face, hands) of fair-skinned individuals.
Around age 35, female fertility declines sharply.
• In the mid-forties, presbyopia generally
becomes apparent. Around age 50, hair
turns grey in Caucasoids.
• Many men are affected by balding, and
women enter menopause. In the 60-64
age cohort, osteoarthritis rises to 53%.
Only 20% however report disabling
osteoarthritis at this age.
• In the 70-79 age range, partial
hearing loss affecting communication
rises to 65%, predominantly among
low-income males.
• Over the age of 85, thirst perception
decreases, such that 41% of the
elderly drink insufficiently. Frailty,
defined as loss of muscle mass and
mobility, affects 25% of those over
85.
SECTION 2
COMMUNICATION
CHAPTER 4
Aging Changes That Affect Communication
Communication – is an important skill
that allows us to survive in and interact
with our world. Through our ability to
communicate, we express our needs and
wishes, understand the needs and
wishes of others, negotiate adversity,
and convey our feelings. Losing our
ability to communicate effectively
compromises our independence.
Types of Communication
1. Verbal Communication
2. Non-Verbal Communication
Sensory Modalities Involved In Communication
1. Vision – has an important role in
communication, with approximately
70% of all sensory information
coming through the eyes.
(Springhouse, 2001)
2. Hearing – is another prominent sense
involved in the reception of
communication. A major source of
communication is the content of
auditory verbal information that is
conveyed in conversations as well as
radio, television, or computers.
Sensory Modalities Involved In Communication
3. Speech – is the primary form of
communication with our
environment. Speech is a very
complex process that requires both
visual and auditory input, motor
output to both facial and vocal
muscles, and central processing that
takes place in multiple brain
locations. (Beers & Berkow, 2000)
4. Disability – (Physical Impairment)
also plays a major role in affecting
communication. Disability may affect
our ability to convey or receive
3. Speech – is the primary form of
communication with our
environment. Speech is a very
complex process that requires both
visual and auditory input, motor
output to both facial and vocal
muscles, and central processing that
takes place in multiple brain
locations. (Beers & Berkow, 2000)
4. Disability – (Physical Impairment)
also plays a major role in affecting
communication. Disability may affect
our ability t
Role of the Brain in Communication
The brain has a major role in attending to

new information, making sense of and
organizing information, deciding on a
response.
Areas of the brain Important for

Communication
1. Cortex – is a large, wrinkly sheet of

neurons that covers the brain. The cortex
contains all the brai’s sensory and motor
information as well as our thoughts.
2. Thalamus – Information that is
perceived through our sensory system
goes to the thalamus, a relay station in
the center of our brain. It is then
transferred via the neurons into the
sensory cortex. The sensory area of the
cortex is located on a vertical strip
near the center of the skull. Sensory
information is represented on this strip
in relation to the sensitivity of each
body part, and not in relation to its
actual size.
3. Forebrain – From the sensory cortex,
information is sent to higher-order
parts of the brain, such as the
These areas integrate the sensory
information and interpret it based on past
experiences, overall arousal level, and
the array of sensory information already
available to us. (Atrens & Curthoys, 1978;
Howard Hughes Medical Institute, 2005).
Dementia – is a case of
Neurodegenerative disease when the
brain’s ability to understand information
and to communicate verbally
deteriorates, older adults may resort to
alternative forms of communication.
For example, an older adult may put an
item in his or her mouth in order to
better recognize the item, or he or she
may scream to communicate distress.
Vision
1. The Lens – with age the lens changes

in color, becoming more yellowed or
amber, and more opaque, this makes it
difficult for the aging eye to distinguish
colors on the blue-green hue range. The
lens becomes flattened, denser, and less
flexible (Gray, 1995)
2. The Iris and Pupil – starting at the age
of 50, the pupillary reflex responds
more slowly, and the pupil does not
dilate completely (the size of the pupil
declines – senile miosis) making it
more difficult to see in lower light and
thus adapt to the dark quickly.Less
light enters the eye, older adults
require more light than youger adults
at a rate of approximately 10% more
every 10 years (Stuen & Faye, 2003).
Behavioral Cues to Visual Deficits
1. Visual Difficulty
2. Activity of Daily Living (ADL’s)
Common Visual Diseases
3. Macular Degeneration – occurs
bilaterally in which neurons in the
center of the retina (macula) are
damaged and no longer function due
to hardening and blocking of the
retinal arteries, resulting in blurred
vision and loss of central vision. Can
lead to blindness.
2. Diabetic Retinopathy – a long term
effect of Diabetes Mellitus. The blood
vessels to the eyes grow weak and
rupture, causing leakage into the eye
and vision loss. (creating blind spots)
leading to blindness
3. Glaucoma – most common type is the
wide angle glaucoma. 2% of the older
adult population is affected by this
visual disease it can lead to blindness.
Characterized by a build up of viscous
fluid (aqueous humor) creates
pressure and damages the optic
4. Senile Cataracts – are most commonly
found in adults over 70 years old. It
refers to the clouding of the lens
which blocks the path of light through
the lens and can blur the image that is
reflected onto the retina, resulting in
hazy vision.
5. Retinal Detachment – is more common
in men than in women. This condition
occurs when the retina separates from
the back of the eye and fills with
vitreous fluid.
Hearing
Hearing Loss is a commonly observed
phenomenon in older adults and is one
of the most common chronic disabilities
in the United States.
Typical Age Related Changes in Hearing
Types of Hearing Loss
1. Conductive Problems – result in a
reduction of sound transmission such
that sound waves are blocked as they
travel from the outer ear canal to the
inner ear, resulting in a decrease in
hearing sensitivity. Conductive loss
can be caused by anything that blocks
Types of Hearing Loss
eternal ear, but excessive wax (cerumen)
buildup is the most common cause of
conductive problems with nearly one in
three older adults having their hearing
reduced by up to 35%.
2. Sensorineural Problems – Sound wave
transmission can be interrupted from
the inner ear to the auditory cortex of
the brain, most likely due to the
damage to the cochlea and/or
auditory nerve. It is caued by both
genetic and acquired factors (ex.g.
noise pollution, ototoxic subtances).
Presbycusis (“old man’s hearing”) – most
common form of age-related hearing loss.
It is ranked 4th in the chronic disability in
older adults. It has a gradual onset and is
typified by problems hearing high-pitched
tones and a decrease in speech
discrimination.
3. Mixed Hearing Loss – is simply a mixture

of both sensorineural and conductive
hearing loss.
Pathological Changes to Hearing
1. Persistent Exposure to Noise Pollution
Tinnitus – a condition in which the
person experiences a persistent ringing,
buzzing, humming, roaring, or other
noise in the ears that only the person
can hear. It is often perceived as
annoying or distracting, and has been
associated with reduced quality of life in
older adults.
2. Exposure to Ototoxic Substance
Ototoxic Susbtances
a. Medications – including aspirin,
antibiotics, diuretics, and
antidepressants, can cause symptoms
of tinnitus. These losses are typically
permanent and do not remit after
removal of the medication.
b. Poisons – such as arsenic, lead, or
mercury are toxic to the inner ear and
typically affect the eight cranial nerve.
Exposure to these substances may lead
to either temporary or permanent
hearing loss.
3. Difficulties Detecting Hearing Loss
Ototoxic Susbtances
4. Medications – including aspirin,
antibiotics, diuretics, and
antidepressants, can cause symptoms
of tinnitus. These losses are typically
permanent and do not remit after
removal of the medication.
2. Poisons – such as arsenic, lead, or
mercury are toxic to the inner ear and
typically affect the eight cranial nerve.
Exposure to these substances may lead
to either temporary or permanent
hearing loss.
3. Medical Conditions
• Acute trauma, or damage at the level of
the central nervous system, can be due
to head trauma (most likely caused by
falls) if the damage is to the eight
cranial nerve, then sensorineural loss
will be observed. If the damage is to the
temporal lobe (the cortex), a loss of
certain frequencies and pitches occurs.
• Cardiovascular disease – high blood
pressure is a treatable cause of
tinnitus.
• Cigarette smoking can aggravate
tinnitus.
• Chronic viral or bacterial infections in
• Exposure to measles, mumps, or
meningitis can lead to sensorineural
deficits.
4. Difficulties Detecting Hearing Loss

Despite the fact that hearing loss is a
common occurrence in older adults, it is
not routinely assessed.
5. Indications of Hearing Loss
Hearing impairment may lead to the
following behaviors:
• Inattentiveness and/or inappropriate
responses or no response to questions.
• Asking repetitious question, or asking
for things to be repeated.
• Complaints that other people are
“mumbling” or have ome other speech
impediment.
• An increased reaction to loud ounds (as
in presbycusis).
• Increased or unusually loud speech
with some type of background noise.
• Tilting/cocking head toward a sound in
an attempt to facilitate hearing.
• Turning the volume up on the radio or
television to higher than normal levels.
Isolation – or emotional upset often occur
as a result of problems in communicating
with others, either in group setting or
individually.
6. The Impact of Hearing Deficits on
Communication
Speech and Language
Normal Aging Changes in Speech and
Language
Normal age-related changes in

speech and language occur as a result of
physiological and cognitive changes.
Pathological Changes in Speech and
Language
1. Dysarthria – is disturbed articulation
caused by disturbance in the control of
the speech muscles. This is caused by
brain lesions in motor areas in the
central nervou system or the brain
stem or disruption in the coordination
of information from the basal ganglia,
cerebellum, and motor neurons.
Anarthria – complete inability to move the
articulators for speech). They may
manifest:
a. Slurred speech
Language
d. limited mouth or facial movement
e. Monotonous voice
f. Weak articulation
2. Verbal Apraxia – is a disorder caused by
damage primarily to the parietal lobe
(the part of the brain involved with
somatosensory processing). This is a
neurological disorder characterized by:
a. Impairment in initiation
b. Coordination
c. Sequencing of muscle movement, which
results in difficulties executing mouth
Language
3. Aphasia – is the most common language
disorder in the elderly and occurs in up to
a third of the patients in an acute phase
following stroke. It is the inability to
express or understand the meaning of
words due to damage in the language
areas. Damage is most frequently due to
stroke in the left hemisphere, but can be
due to stroke in the left hemisphere, but
can be due to brain tumor, trauma,
infection, dementia or surgery.
Receptive (Fluent) Aphasia is
written language but intact expressive
ability.
Wernicke’s Area – receptive (fluent)

aphasia is a result of the damage in the
wernicke’s area of the brain.
Broca’s Area – aphasia is due to the
damage in the broca’s area.
Other Medical Conditions that may cause
Impairment in Speech
1. COPD
2. Use of Mechanical Ventilators
3. Laryngectomy
Touch
Somatosensory System are consists:
a. Touch
b. Pressure
c. Vibration
d. Pain
e. Temperature
Reduced somatosensory sensitivity in

the elderly has been associated with an
increase in injuries such as hypothermia,
burns, or pressure ulcers. Reduced tactile
perception also been associated with
postural inability and with the difficulties
of older adults to position and orient their
The Impact of Somatosensory Deficits on
Communication
When older adults present with
injuries, it is important not to blame or
interpret the injuries as intentional, but
instead try to identify alternative means to
communicate the very essential
somatosensory information. Example is
teaching an older adult to read the
thermostat in the mercurial thermometer.
Movement
Movement is an important ability that
fosters independence and promotes
interaction and understanding of the
Movement
Gross Motor Movement – movement

produced by the large muscle.
Fine Motor Movement – movement

produced by the small muscle.
Velocity – speed and accuracy and greater
variability across individuals.
Movement Disorders in Older Adults
1. Parkinson’s Disease (PD) is a chronic
neurodegenerative copndition
characterized by impairment in the nerves
that control movement.
Disability
With advanced age, older persons
experience more chronic illnesses and
disability. A decrease in the ability to
perform ADLs and IADLs independently
can have a negative impact on the older
person’s quality of life.
Cognitive Changes
There is a high variabilty in cognitive
functioning both within individuals and
across individuals.
1. Fluid Intelligence – believed to decline
over time.
Disability
Cognitive Changes
2. Crystallized Intelligence (Accumulation
of Knowledge) is believed to remain
stable.
Information Processing Speed – the time it
takes to analyze data.
Divided Attention – the ability to attend to
and analyze two stimuli presented
simultaneously.
Sustained Attention – ability to focus
cognitive activity on a stimulus.
Disability
Cognitive Changes
Long Term Memory – Large storage
capacity for information for long periods of
time or even indefinitely.
Short Term Memory – modest capacity for
storing information for a few seconds. It
has milder decline with age.
Verbal Comprehension and Expression –
remain stable.
Vocabulary may improve with age.
Pathological Cognitive Changes
Delirium – is define as:
1. Disturbance of consciousness with
reduced ability to focus, sustain, or shift
attention.
2. A change in cognition 9such as memory
deficit, disorientation, language
disturbance) or the development of a
perceptual disturbance that is not
better accounted for by a preexisting,
established or evolving dementia.
3. The disturbance develops over a short
period of time (usually hours to days)
and tends to flactuate over the course
of the day.
Delirium – is define as:
4. There is evidence from the history,
physical examination or laboratory
findings that the disturbance is caused by
several different possible events including
general medical conditions (cancer, AIDS),
metabolic disturbances (including
electrolyte disturbances as occurs with
dehydration drug intoxication, drug
withdrawal, drug side-effects, and multiple
etiologies.
Delirium
Guidelines for Communicating with the
Delirious Elderly
1. Keep discussions simple and questions
concise.
2. Use large-print calendars and clocks to
assist with orientation to time.
3. Pictures of family members and loved
ones might assist in reorienting the
elder.
4. Some older adults may experience an
increased state of delirium in the
darkness; thus, a well-lit place might be
Delirium
Guidelines for Communicating with the
Delirious Elderly
5. Offer frequent reassurance, because the
person is likely to be anxious and fearful.
Physical restraints are not recommended,
because they may increase fear and
agitation. Distraction and soothing
conversation should be tried instead.
Dementia – is a progressive illness that
impairs social and occupational
functioning. It is define as:
Dementia
1. Development of Cognitive Deficits
• The person cannot recall new or
previously learned information.
• Memory problems must be present.
2. One or more of the following:
a. Apraxia – impaired motor activities due
to damage to motor cortex (e.g. the
person cannot use a key).
b. Aphasia – language disturbance (e.g.,
cannot find words or put sentences
together).
Dementia
2. One or more of the following:
c. Agnosia – failure to recognize or identify
objects (e.g., the person may see
something but cannot label it or tell what
it is used for0
d. Disturbed executive functioning –
planning, organizing, sequencing, and
abstracting problems due to frontal lobe
damage.
Types
1. Reversible – also referred to as
pseudodementias. Potential for
Dementia
Types
2. Irreversible – refers to the inability to
cure or reverse the symptoms with medical
or psychological treatment.
Alzheimer’s Disease – is responsible for

50-60% of all dementias in adults over the
age of 60.
3 Stages of the Progression of the
Dementia in Alzheimer’s Disease
1. Stage 1 (duration 2-4 yearts, leading up
to and including diagnosis)
Dementia
1. Stage 1 (duration 2-4 years, leading up

• Progressive memory loss.
• Mood and personality changes may
become more labile or depressed.
• Loss of spontaneity and initiative in
verbal and non-verbal communication
and activity engagement.
• Decreased concentration abilities.
• Impaired judgement and thinking.
Dementia
1. Stage 1 (duration 2-4 yearts, leading up

• Progressive memory loss.
• Mood and personality chan
Dementia
2. Stage 2 (duration 2-8 years)

• Increasing memory loss and confusion.
• Difficulty recognizing loved ones.
• Poor impulse control with frequent
outbursts mood lability.
• May display aggressive behavior.
• Hallucinations or delusions.
• Aphasia and confabulation (filling in
words or memory gaps with information
that is made up in order to compensate
Dementia
memory loss
• Agraphia – (inability to write)
• Agnosia
• Repetitive behaviors are common;
wandering and restlessness.
• Hyperorality ( the need to taste and
orally examine objects small enough to
be placed in the mouth)
• Loss of weight or conversely binge
Dementia
and weight gain.
• Loss of most self-care skills.
• Incontinence of urine and bowel.
• Minimal to no communication, may
scream.
• Multiple physical health problems and
eventual death.
• Progressive decrease in ability to
respond to environmental stimuli.
Alzheimer’s Disease
Has been deemed a disease of “rule
out”. Although neuropsychological testing
can be very useful in clinical diagnosis,
curretly no definitive diagnosis can be
made until after death, when autopsy can
be performed and the hallmark
pathophysiological features can be
identified.
Delirium and dementia are not necessarily
mutually exclusive. Delirium can occur in a
person with dementia, making accurate
diagnosis and treatment difficult.
Psychological Changes
The prevalence of mental illness (with
the exception of cognitive impairment) in
older adults is lower than in the general
population.
Depression – is a very serious condition
characterized by at least five of the
following symptoms:
1. Sadness
2. Anhedonia
3. Significant weight loss or gain
4. A marked decrease or increase in sleep
5. Psychomotor agitation or retardation
6. Fatigue or loss of interest
7. Feelings of worthlessness or
The prevalence of mental illness (with
the exception of cognitive impairment) in
older adults is lower than in the general
population.
characterized by at least five of the
following symptoms:
guilt
8. Impaired ability to concentrate or think
9. Recurrent thoughts of death including
suicide ideation or attempts
Clinical depression – is more intense,
broader, and lasts for at least 2 weeks.
that is associated with increased risk of
death (either from medical conditions or
from suicide).
Unique Characteristics of Depresssion in

the Elderly
1. Depression in the elderly often is

associated with multiple medical
conditions that limit functioning and
mobility.
2. It is also associated with life transitions
and with a change in status and role as
Unique Characteristics of Depresssion in
the Elderly
transition out of the workforce and
have to find a new sense of purpose and
meaning in their life.
3. Loss of family members and friends
also is common in older adults who may
experience a reduced support system.
4. Many times, depressed older adults do
not report adults do not report depressed
mood, but instead present with lack of
interest enjoyment as well as sleep and
appetite problems that are mistaken for
other medical conditions.
Electroconvulsive Therapy – (ECT) the
delivery of an electrical shock that causes
electrical activity in the brain. It is an
effective alternative especially when
antidepressant medications can not be
taken due to their side effects or due to
interaction with other medications.
CHAPTER 5
Therapeutic Communication With Older Adults
Communication – is a core skill in the
health care professions. We rely on our
ability to communicate effectively to
gather and share information as well as
to build relationships with patients and
families. Learning and practicing the art
of communication is one key to success
as clinicians.
Anatomy and Physiology of

Communication
Communication is used frequently in our

language and in our work. The term
originates from the Latin word
By virtue of its origins, the word implies
that communication is a process that
involves more than one person.
Communication is the process or means by
which an individual relates experiences,
ideas, knowledge, and feelings to another.
Repository of Cognition
1. Cortex of the Brain
2. Language – is the use of symbols or
gestures that are common to groups
and serve as a means of sharing
thoughts, ideas, and emotions.
Aphasia – an acquired loss or impairment

of language. The most common cause of
The most common cause of aphasia is the
brain damage that occurs with a stroke.
Speech – refers to oral communication of

the sounds or words associated with
language.
Dysarthria – when damage occurs to the

oral muscles, the individual may have
difficulty producing sounds or words that
can be understood by others. It refers to a
group of neuromuscular disorders that
affect the speed, strength, range, timing,
or accuracy of speech movements, which
often result in reduced intelligibility of
Assistive Technology is use to augment or
replace vocal communication.
Types of Communication
1. Verbal Communication – uttered words.
2. Non-verbal Communication – refers to
gestures and actions.
A student nurse on rounds enters a

patient’s room and finds an older woman
sitting comfortably in a wheelchair in no
apparent distress staring out the window
with her back to the nurse. Is this patient
inviting communication from the nurse?
Based on the patient’s position and
posture, the nurse may elect to not speak
or say anything, fearing she might disturb
the patient. Shortly, the staff nurse enters
the room and comments, “Mrs. Hale are
you waiting for someone? Can I do
anything to help you get ready for a visit?
Mrs. Hale responds, “I am waiting for my
son. He is generally on time. I hope
nothing bad has happened. I would like to
go to the bathroom before he arrives so I
don’t have to worry about that during his
visit.”
• What is the nurse’s most appropriate

• Should the student nurse have done
anything differently during her visit to
the room on rounds? If so, what?
• What nonverbal communication would
the nurse expect to see from Mrs. Hale?
• What non-verbal communication should
the nurse include in her care of this
woman?
Alternative Communication and Assistive

Technology
Assistive Technology can help individuals

improve their mobility, communication,
self-care, or vocational skills. Assistive
System, whether acquired commercially
off the shelf, modified, or customized, that
is used to increase, maintain, or improve
functional capabilities of individuals with
disabilities.
Hearing aid – is an ear-level or body-worn

electronic device that uses a tiny
microphone to pick-up sound waves,
change weaker speaker sounds, and
modify ear via a tiny speaker.
Types
1. BTE (Behind the Ear) are about 1 inch
long and worn behind the outer ear.
Types
1. BTE (Behind the Ear) are about 1 inch
long and worn behind the outer ear.
2. OTE (Over the Ear) this is a new style
that is very small and sits on top of the
outer ear.
3. ITCs ( In the Canal) are tiny devices that
fit into the ear canal are barely visible.
They are customized to fit the size and
shape of the ear canal.
4. CIC (Completely in the Canal) are the
smallest type of device in the ear class.
Augmentative and Alternative
communication (AAC) system is “an
integrated group of components,
including symbols, aids, strategies and
techniques used by individuals to enhance
communication.
Communication in Healthcare
1. Instrumental or task Focused

Communication – refers to behavior
necessary for assessing and solving
problems.
Communication in Healthcare
2. Affective Communication - which

focuses on how the health care
provider is caring about the patient and
his or her feelings and emotions.
Affective communication tend to be
more informal and more difficult for
health care providers.
Communication in Health Care
1. Communicating with the Older Adult

2. Inviting
3. Arranging the Environment
4. Maximizing Understanding
Healthy Literacy – is defined as “the

degree to which individuals have the
capacity to obtain, process, and
understand basic health information and
services needed to make appropriate
health decisions”.
5. Following Through – a relationship built

Speech Deficits or Impairments
1. Aphasia – is an acquired loss or

impairment of language that occurs as
a result of damage to the speech
centers in the dominant hemisphere of
the brain.
2. Dysarthria – can occur secondary to a
number of diseases. Even the loss of
dentition that occurs with aging may
predispose the individual to dysarthria.
The difficult to understand when they
are speaking.
SECTION 3
ASSESSMENT &
TECHNICAL SKILLS
CHAPTER 6
Review of the Aging of Physiological Systems
THE CARDIOVASCULAR SYSTEM
Main Function: Hemeostasis – equilibrium
Components
1. Heart
2. Blood
3. Associated Vasculature
4. Heart
a. 2 Upper Atria
b. 2 Lower Ventricles
Blood Pressure – Systolic and Diastolic

Pressure
Aging Changes in Cardiovascular System
1. Cardiomegaly – Enlargement of the

heart.
2. Vascular Aging – The arteries and veins
of the body are greatly affected by the
aging process.
Cardiovascular Aging Mechanisms
Potential Mechanisms
1. Free radicals - are chemical species that
arise from atoms as single unpaired
electrons. Free radical molecule is unpaired
so it is able to enter reactions with other
Potential Mechanisms
especially along membranes and with
nucleic acids.
2. Lipofuscin – a brown pigment found in
aging cells, relates to oxidative
mechanisms.
A. CARDIAC AGING
B. VASCULAR AGING
Autonomic Nervous System Aging Effects

1. Orthostatic Hypotension
B. VASCULAR AGING
Autonomic Nervous System Aging Effects
3. Over stimulation of .
4. a-adrenoceptors that control vessel
dilation remain stable with age.
5. Decreased Stimulation of Baroreceptors.
Exercise and Aging
When older adults exercise, the
cardiovascular response is different from
the response is different from the response
of younger individuals.
Apoptosis – cell death. It can have
detrimental effects on cardiovascular
structure and functioning.
Acyanotic Heart Disease
Acyanotic heart disease is a broad term

for any congenital heart defect in heart
passes through the lungs and pulmonary
vasculature in the normal fashion. The
common forms of acyanotic congenital
heart defects are those where there is a
defewhich all of the blood returning to
the right side of the ct in one of the walls
separating the chambers of the heart, or
obstruction to one valve or artery.
THE RESPIRATORY SYSTEM
Lifestyle Interventions to Maintain or
Improve Physiological Functioning in
Aging
Physical Activity
1. Exercise at least 30 minutes.
2. Include cardio training, weight-bearing
exercise, resistance, balance training,
and flexibility exercise
Nutrition
1. Low calorie diet
2. Low fat diet
3. Low cholesterol diet
4. Low sodium diet
Lifestyle Interventions to Maintain or
Improve Physiological Functioning in
Aging
Nutrition
6. Plenty of whole grain
7. Eight glasses of water a day
Vitamins and Minerals

1. Vitamins B6, B12, D, K, A C, E, beta,
carotene, and folic acid
2. Minerals; selenium, calcium and iron
Aging of the Respiratory System
1. Alveoli
30 years old – 75 square meters
70 years old – 60 square meters
2. Lung Elasticity
Elastic Recoil properties of the lungs
3. The Chest Wall
Acyanotic Heart Disease
Acyanotic heart disease is a broad term

for any congenital heart defect in heart
passes through the lungs and pulmonary
vasculature in the normal fashion. The
common forms of acyanotic congenital
heart defects are those where there is a
defewhich all of the blood returning to
the right side of the ct in one of the walls
separating the chambers of the heart, or
obstruction to one valve or artery.
ACYANOTIC HEART DISEASE
• Acyanotic heart disease is a broad term for
any congenital heart defect in heart passes
through the lungs and pulmonary vasculature
in the normal fashion. The common forms of
acyanotic congenital heart defects are those
where there is a defewhich all of the blood
returning to the right side of the ct in one of
the walls separating the chambers of the
heart, or obstruction to one valve or artery.
Common Acyanotic Heart Diseases
• Atrial/Ventricular septal defects
• Patent ductus arteriosus
• Pulmonary stenosis
• Aortic stenosis
• Mitral stenosis
• Coarctation of aorta
ASD
• An atrial septal defect
(ASD) is a hole in the
wall between the two
upper chambers of your
heart (atria). The
condition is present
from birth (congenital).
Small atrial septal
defects may close on
their own during
infancy or early
childhood.
Types
• Secundum. This is the most common type of ASD,
and occurs in the middle of the wall between the
atria (atrial septum).
• Primum. This defect occurs in the lower part of the
atrial septum, and may occur with other congenital
heart problems.
• Sinus venosus. This rare defect occurs in the upper
part of the atrial septum.
secondum primum
Signs and Symptoms
• Shortness of breath, especially when
exercising
• Fatigue
• Swelling of legs, feet or abdomen
• Heart palpitations or skipped beats
• Frequent lung infections
• Stroke
• Heart murmur, a whooshing sound that can be
heard through a stethoscope
Risk Factors
• Rubella infection.
• Drug, tobacco or alcohol use, or exposure to certain

substances.
• Diabetes or lupus.
• Obesity.
• Phenylketonuria (PKU).
Diagnostic Tests
• Echocardiogram.
• Chest X-ray
• Electrocardiogram (ECG)
• Cardiac catheterization.
• Magnetic resonance imaging (MRI).
• Computerized tomography (CT) scan.
Treatments
• Medications
– beta blockers
– anti coagulant
• Surgery
– Cardiac catheterization.
– Open-heart surgery
Health Education
• avoid strenuous activity or exercise
• healthy diet
• prevent infection
• Prevention
– Getting tested for immunity to rubella.
– Going over your current health conditions and
medications.
– Reviewing your family medical history
PDA
• Patent ductus arteriosus (PDA) is a persistent
opening between two major blood vessels
leading from the heart.
Symptoms
• Poor eating, which leads to poor growth
• Sweating with crying or eating
• Persistent fast breathing or breathlessness
• Easy tiring
• Rapid heart rate
Risk Factors
• Premature birth.
• Family history and other genetic conditions.
• Rubella infection during pregnancy.
• Being born at a high altitude.

Complications
• High blood pressure in the lungs (pulmonary
hypertension)
• Heart failure
• Heart infection (endocarditis)
Diagnostic Tests
• Echocardiogram.
• Chest X-ray.
• Electrocardiogram (ECG).
• Cardiac catheterization.
Treatments
• Watchful waiting.
• Medications
– NSAID'S
• Surgery
– Open-heart surgery
– Catheter procedures.
Health Education
• Preventing infection.
• Exercising and play.
• prevention
– Seek early prenatal care
– Eat a healthy diet
– Exercise regularly
– Avoid risks
– Avoid infections
Pulmunary Stenosis
• Stenosis means narrowing. Pulmonary
stenosis is then a narrowing of the pulmonary
valve. Normally the pulmonary valve opens to
let low oxygen blood flow from the right
ventricle to the lungs where the blood is
oxygenated. Because of the narrowing the
right ventricle has to pump harder to get past
the stenotic valve.
Aortic Stenosis
• Aortic stenosis is then a narrowing of the
aortic valve or a narrowing of the aorta
directly above (supravalvar) or below
(subvalvar) the aortic valve
Mitral Valve Stenosis
Coarctation of Aorta
• The aorta is the main
artery that sends
oxygen rich blood from
the heart to the body.
Coarctation of the aorta
is a constricted segment
of the aorta that
obstructs blood flow to
the body.
CANCER
• Abnormal Tumor
• Malignant Tumor
• Malignant Neoplasm
• Neoplasia – Formation of abnormal cell
Factor’s Affecting Cancer
• Race
• Age can be controlled
• Gender
• Occupation - Cannot be controlled

Sign’s & Symptoms
• new lump
• abnormal bleeding
• a prolonged cough
• unexplained weight loss
• and a change in bowel movements
• Single most lethal factor affecting cancer
TOBACCO SMOKING
Characteristics
• Benign – not cancerous
• Malignant – Cancerous / likely to grow and

spread in a rapid and uncontrolled way that
can cause DEATH
INCIDENCE
• MALE – PROSTATE CANCER

• FEMALE – BREAST CANCER
TOP 10 common cancer in the Philippines
(2014)
• Breast Cancer
• Lung Cancer
• Liver Cancer
• Cervical Cancer
• Colon Cancer
• Thyroid Cancer
• Rectal Cancer
• Ovarian Cancer
• Prostate Cancer
• Non-Hodgkin’s lymphoma
BREAST CANCER
• is cancer that develops from breast tissue

• It is the leading type of cancer in women
• Breast Cancer metastasizes most commonly to
auxillary nodes,lung,bone, liver and brain.
Sign’s and Symptoms
• lump in the breast

• a change in breast shape
• dimpling of the skin
• fluid coming from the nipple
• a red scaly patch of skin
Risk Factors
Most common RF’s are gender (being a woman)
and age (growing older)
• lack of physical exercise
• drinking alcohol
• early age at first menstruation
• having children late or not at all
• About 20-30% of women diagnosed w/ BC
have family history of BC.
Management
Surgical Management
• Mastectomy: Removal of the whole breast.
• Quadrantectomy: Removal of one quarter of
the breast.
• Lumpectomy: Removal of a small part of the
breast.
Nursing Management
• Teach all women the recommended cancer-
screening procedures
• Provide psychological support of the patient
throughout the diagnostic and treatment
process.
• Help patient identify and use support persons
family/community.
PROSTATE CANCER
• Also known as CARCINOMA OF THE PROSTATE
Is the development of cancer in the prostate, a
gland in the MALE reproductive system.
Most prostate cancers are slow growing;

however, some grow relatively quickly.
• Can spread to the prostate and other parts of
the body, particularly the bones & lymph
nodes.
Risk Factors
• age
• race or ethnicity
• family history
Signs & Symptoms
• obstructed urinary flow, including hesitancy and
straining on voiding, frequency, nocturia, reduced size
and force of urinary stream.
• A firm to hard nodule may be felt on rectal examination
of the prostate.
• Pain in lumbosacral area radiating to hips and down leg
(from bone metastases).
• Perineal and rectal discomforts.
• Anemia, weight loss, weakness, nausea, oliguria .
• Low extremity edema – occurs when pelvic node
metastases compromise when venous return.
Pathophysiology
Diagnostic Evaluation
• Needle biopsy (through anterior rectal wall or

through perineum) for histologic study of
biopsy tissue or aspiration for cytologic study.
• Prostate-specific antigen (PSA)
• DRE
• Metastatic workup - include skeletal x-ray, bone
scan, and CT or MRI to detect local extension,
bone, and lymph node involvement.
Management
Surgical
• Radical prostatectomy – removal of entire
prostate gland
• Cryosurgery- freezes prostate tissue, killing
tumor cells without prostatectomy.
• Bilateral orchiectomy (removal of testes)
Nursing Management
• Teach relaxation techniques such as imagery,

music therapy, and progressive muscle
relaxation as adjunct to pain control.
• Suggest options such as sexual counseling,

learning other options of sexual expression,
and consideration of penile implant.
• Advise the patient to report symptoms of
worsening urethral obstruction, such as
increased frequency, urgency, hesitancy, and
urinary retention.
• Encourage all men to seek medical screening

for prostate cancer.
COPD: Chronic Bronchitis
What is Chronic Bronchitis?
• Bronchitis is the inflammation of the lining of

the airways, or bronchial tubes. When your
airways are inflamed and/or infected, less air
is able to flow to and from the lungs and you
cough up heavy mucus or phlegm.
• A person with chronic bronchitis has a mucus-
producing cough for at least three months of a
year for two years in a row without other
underlying disease to explain the cough.
Pathophysiology
Assessment
• History taking:
– Exposure to toxic substances
– Smoking
• Hypertrophy of mucous glands
• Excessive mucous production (thick,
gelatinous sputum)
• Productive cough
• Dyspnea and wheezing
Management
Medical Management:
• Smoking cessation.
• Low-flow oxygen to correct severe hypoxemia and
minimized C02 retention.
• Chest physical therapy:
– Postural drainage and breathing retraining.
• Bronchodilators to reduced dyspnea and bronchospasm.
• Corticosteroids (anti-inflammatory)
• Antimicrobials to prevent secondary bacterial infections
in the bronchial tree.
Nursing Management:
• Eliminate pulmonary irritants, particularly cigarette smoke.
• Monitor O2 saturation.
• Monitor for adverse effects of bronchodilators:
– Tremors, tachycardia, cardiac arrhythmias, hypertension.
• Use postural drainage to help clear secretions.
• Give nebulized saline to humidify bronchial tree and
liquefy sputum.
• Use portable O2 for ambulation for clients with
hypoxemia.
Health Education
• Encourage the client to stop smoking.
• Teach controlled coughing.
• Increase fluid intake within level of cardiac reserve.
• Pursed lip breathing.
• Discuss relaxation exercises to reduce stress and
anxiety.
• Avoid dairy products if it increased sputum production.
• Encourage the client in energy conservation.
• Assume comfortable position to decrease dyspnea.
Quit Smoking
• Stopping smoking at any age will have a
beneficial effect on your lungs.
– Write down reasons for stopping.
– Try find a pattern of smoking habits.
– Find someone who can support you, friends or
doctor. (Join quit smoking group)
– Nicotine patches or chewing gum may help.
How to make breathing easier
• Breathing techniques can help lungs work effectively and
helps to relax when short of breath.
– Breathe with the stomach
• Breathe in through your nose as you count to 3. Breathe out as you
count to 6, holding your breath for the last 2 seconds.
• Repeat this approximately for 15 minutes.
– Tight-lipped breathing
• Breathe in slowly through your nose.
• Tighten your lips a little and breathe out slowly.
• Try combining tight-lipped breathing and breathe with the
stomach techniques.
Get rid of phlegm
• Controlled coughing can help cough up
phlegm without getting short of breath or
damaging respiratory passages.
– Take a slow, deep breath through the nose.
– Hold breath for a couple of seconds.
– Open mouth and cough 2 to 3 forceful coughs.
Active life despite the condition
• Exercise
People who are fit use less oxygen.
• Travel
– Asked doctor about medical facilities on places you planned to visit.
– Take supplied medicines.
• Manual work or Houseworks
– Conserve energy. Break hard task into smaller parts.
– Rest every now and then. Use tight-lipped breathing.
– When possible, push and pull instead of lifting.
– Use relaxation techniques.
Family Members
• Share emotions. It could help with the need to share
your feelings and emotion.
• Give full support if the client wants to quit smoking.
• Don’t overprotect. Let the client who needs help do
as much as they can by themselves. Their self-
confidence depends on it.
• Join a support group. Talking to other families
affected by the disease can help with coping.
Issues and Trends
• In April 2014, the FDA approved UMECLIDINIUM
inhalation powder, a bronchodilator also known as a
long-acting anticholinergic.
• It is indicated for the long-term, once-daily maintenance
treatment for patients with COPD including Chronic
Bronchitis and Emphysema.
• It is available as a powder for inhalation via a plastic
inhaler.
• The most commonly reported adverse effects include
cough, arthralgia, upper respiratory tract infection, and
nasopharyngitis.
• In August 2014, the FDA also approved
OLODATEROL inhalation spray, a long-acting
beta2-agonist bronchodilator.
• This long-term maintenance medication is
administered once daily.
• The most commonly reported adverse reactions
include nasopharyngitis, upper respiratory tract
infection, urinary tract infection, cough, dizziness
rash, diarrhea, back pain, and arthralgia.
CYANOTIC HEART DISEASE
• Cyanotic Heart Disease occurs when there is
mixing of pure oxygen-rich blood with venous
blood. Infants suffering from cyanotic
conditions usually have blue nail beds and lips
due to the excess deoxygenated blood in their
systems
Common Cyanotic Heart Diseases
Tetralogy of Fallot
Tricuspid Atresia
Truncus Arteriosus
Ebstein’s anamoly
Transposition of the Great Vessels
Hypoplastic Left Heart Syndrome
Tetralogy of Fallot
• Tetralogy of Fallot (teh-tral-uh-je ov fuh-LOE)
is a rare condition caused by a combination of
four heart defects that are present at birth.
These defects, which affect the structure of
the heart, cause oxygen-poor blood to flow
out of the heart and into the rest of the body.
Infants and children with tetralogy of Fallot
usually have blue-tinged skin because their
blood doesn't carry enough oxygen
Symptoms
Tetralogy of Fallot symptoms vary, depending on the extent of obstruction of
blood flow out of the right ventricle and into the lungs. Signs and
symptoms may include:
• cyanosis
• Shortness of breath and rapid breathing, especially during feeding
• Loss of consciousness (fainting)
• Clubbing of fingers and toes — an abnormal, rounded shape of the nail
bed
• Poor weight gain
• Tiring easily during play
• Irritability
• Prolonged crying
• A heart murmur
Tet spells
• Sometimes, babies with tetralogy of Fallot will
suddenly develop deep blue skin, nails and lips
after crying, feeding, having a bowel
movement, or kicking his or her legs upon
awakening. These episodes are called Tet
spells and are caused by a rapid drop in the
amount of oxygen in the blood.
Causes
• Ventricular septal defect
• Pulmonary valve stenosis
• Overriding aorta
• Right ventricular hypertrophy

Risk Factors
While the exact cause of tetralogy of Fallot is unknown,
several factors may increase the risk of a baby being
born with this condition. These include:
• A viral illness in the mother, such as rubella (German
measles), during pregnancy
• Maternal alcoholism
• Poor nutrition
• A mother older than 40
• A parent with tetralogy of Fallot
• Babies who are also born with Down syndrome
Diagnostic Tests
• Chest X-ray
• Blood test
• Oxygen level measurement (pulse oximetry)
• Echocardiography
• Electrocardiogram
• Cardiac catheterization
Treatments
• Surgery
– bypass or Shunt (temporary)
– open-heart Surgery (intracardiac repair)
• continuing care / routine checkups
• Preventive Antibiotics
Health Education
• Preventing infection
• limit exercising and play
• employment
• pregnacy
Tricuspid Artresia
• Tricuspid atresia is a heart defect present at
birth (congenital) in which one of the valves
(tricuspid valve) between two of the heart's
chambers isn't formed. Instead, there's solid
tissue between the chambers.
• Babies with tricuspid atresia tire easily, are

often short of breath and have blue-tinged
skin.
Symptoms
Tricuspid atresia symptoms become evident soon after birth, and can include:
• Blue tinge to the skin and lips (cyanosis)
• Difficulty breathing (dyspnea)
• Tiring easily, especially during feedings
• Slow growth
Some babies with tricuspid atresia may also
develop symptoms of heart failure, including:
• Fatigue and weakness
• Shortness of breath
• Swelling (edema) in the legs, ankles and feet
• Swelling of the abdomen (ascites)
• Sudden weight gain from fluid retention
• Irregular or rapid heartbeat
Causes
• A mother who had German measles (rubella) or another viral
illness during early pregnancy
• A parent who has a congenital heart defect
• Drinking alcohol during pregnancy
• A mother who has poorly controlled diabetes
• Use of some types of medications during pregnancy, such as
the acne drug isotretinoin (Claravis, Sotret) and some anti-
seizure medications
• The presence of Down syndrome, a genetic condition that
results from an extra 21st chromosome
complications
• hypoxemia
• Complications later in life
– Although treatment greatly improves the
outcome for babies with tricuspid atresia, they
may still have the following complications later
in life, even after surgery:
• Formation of blood clots that may lead to a clot
blocking an artery in the lungs (pulmonary embolism)
or to a stroke
• Easily tiring when participating in sports or other
exercise
• Heart rhythm abnormalities (arrhythmias)
Diagnostic Tests
• routine ultrasound exam during gestation
• echocardiogram
treatments
• surgery
– Atrial septostomy
– Shunting
– Glenn procedure
– Fontan procedure
• medications
– prostaglandin (prior to surgery)
• continue monitoring
health education
• Strive for good nutrition
• Preventive antibiotics
• Help your child stay active
• Keep up with routine well-child care
Coping
• Try to maintain normalcy and closeness
• Seek support.
• Record your baby's health history.
• Talk about your concerns
prevention
• Get adequate folic acid.
• Talk with your doctor about medication use
• Avoid chemical exposure, whenever possible.
Truncus Arteriosus
• truncus arteriosus is a rare heart defect that's
present at birth (congenital).
• it means that one large blood vessel leads out

of the heart. Normally, there are two separate
vessels coming out of the heart.
Ebstein's anomaly
• Ebstein's anomaly is a rare heart defect that's
present at birth (congenital). In Ebstein's
anomaly, your tricuspid valve — the valve
between the chambers on the right side of
your heart — doesn't work properly. Blood
leaks back through the valve, making your
heart work less efficiently
transposition of the great arteries
• transposition of the great arteries is a serious
but rare heart defect present at birth
(congenital), in which the two main arteries
leaving the heart are reversed (transposed).
Transposition of the great arteries changes the
way blood circulates through the body, leaving
a shortage of oxygen in blood flowing from the
heart to the rest of the body.
Hypoplastic Left Heart Syndrome
• hypoplastic left heart syndrome is a complex
and rare heart defect present at birth
(congenital). In hypoplastic left heart
syndrome, the left side of the heart is critically
underdeveloped.
Pathophysiology of Diabetes
Mellitus 1 & 2
https://www.youtube.com/watch?
v=C9XYnZdEIPE
Diabetes Mellitus Type I
(formerly known as juvenile diabetes or insulin
dependent diabetes)
-onset: acute onset, usually before 30 years of age

-affects approximately 5%-10% of people with the
disease
-characterized by destruction of pancreatic beta cells
-factors: combined genetic, immunologic, and
possibly environmental
Diabetes Mellitus Type II
(formerly referred to as non-insulin-dependent
diabetes mellitus)
- affects approximately 90%-95% of people with

the disease
- onset: occurs more common in people 30y/o &
older
- slow, progressive glucose intolerance, therefore
may go undetected for many years
Assessment
Signs & Symptoms: - Poor skin turgor
- Polyuria
- Polydipsia
- Dry mucous membranes
- Polyphagia r/t dehydration
- Dehydration - Decreased peripheral
- Weight loss pulses
- Fatigue - Cool skin temperature
- Vision changes
- Frequent skin infections
- Decreased reflexes
- Poorly healing skin wounds
- Dry, itchy skin
- Vaginal discomfort
Gerontologic Considerations
• Elevated blood glucose appear to be age related &
occur in both men and women
• Commonly appear in the 5th decade of life
• Possibilities include:
– poor diet
– physical inactivity
– a decrease in lean body mass in which CHO may be stored
– altered insulin secretion
– increase in fat tissue which increases insulin resistance
Management
Medical Surgical
- Main goal: normalize insulin - Amputation
activity & blood glucose - Vascular surgery for large
level vessel disease
- Medications: oral - Pancreas transplantation
antidiabetics - Kidney transplant for renal
- Insulin therapy (rapid, short, failure
intermediate, & very long- - Photocoagulation for
acting) retinotherapy
- Long-term complications:
dialysis
Health Education
• Exercise
• Personalized meal plan
• Limit (best to avoid) alcohol consumption
• Regularly check blood glucose level
• How to self-administer insulin (storage,
selecting syringe, mixing, withdrawing,
selecting & rotating injection site, preparing
skin, inserting needle, disposal
• Coping • Support
- Empowerment - Family
- Self-management - Friends
- Significant other
EMPHYSEMA
PATHOPHYSIOLOGY
Predisposing factors: Long term inhalation of Risk factors:
•Lifestyle harmful substances •Environment exposure and host
•Environment factors
•Cigarette smoking
•Prolonged and intense exposure
Obstruction of walls of
to occupational dusts
over distended alveoli
•Deficiency of a1, anti- trypsin
Alveolar walls continue to Walls of the alveoli are

breakdown destroyed
Respiratory acidosis
Pulmonary capillaries
continually decreases
Increased CO2 tension in
Capillary blood vessel is arterial blood
reduced
Carbon dioxide Increase in dead

Impaired 02
elimination is impaired space
diffusion
Hypoxemia
Cyanosis
Increased pulmonary
artery pressure
EMPHYSEMA
Right sided heart
failure
• Is a long term-progressive disease of the lungs
and occurs when the alveolar walls are
destroyed along with the capillary blood
vessels that run within them. This lessens the
total area within the lung where blood and air
can come together, limiting the potential for
oxygen and carbon dioxide transfer.
• Two main types of emphysema
– Panlobular emphysema
– Centrilobular emphysema
• SYMPTOMS OF EMPHYSEMA
– Shortness of beath
– Wheezing
• MEDICAL MANAGEMENT
– Bronchodilators
– Corticosteroids
– Antibiotics
– Oxygen
• HEALTH EDUCATION
– Maintaining a patent airway is a priority. Use a
humidifier at night to help the patient mobilize
secretions in the morning.
– Encourage the patient to use controlled coughing to
clear secretions that might have collected in the lungs
during sleep.
– Instruct the patient to sit at the bedside or in a
comfortable chair, hug a pillow, bend the head
downward a little, take several deep breaths and cough
strongly.
– Place patients who are experiencing dyspnea in a
High Fowlers position to improve lung expansion.
Placing pillows on the overhead table and having
the patient lean over in the orthopneic position
may also be helpful. Teach the patient pursed-lip
and diaphragmatic breathing.
– To avoid infection, screen visitors for contagious
diseases and instruct the patient to avoid crowds.
– Conserve the patient’s energy in every possible
way. Plan activities to allow for rest periods,
eliminating non essential procedures until the
patient is stronger. It may be necessary to assist
with the activities of daily living and to anticipate
the patient’s needs by having supplies within easy
reach.
– Refer the patient to a pulmonary rehabilitation
program if one is available in the community.
• Teach the patient about the disease and its
implications for lifestyle changes, such as
avoidance of cigarette smoke and other
irritants, activity alterations, and any
necessary occupational changes. Provide
information to the patient and family about
medications and equipment.
• COPING INTERVENTIONS
These suggestions may help patients to cope with having
emphysema:
o Express your feelings. Having ephysema may cause a
gradua change in your lifestyle and that of your family.
Share your feelings and concerns about your disease
with your family, friends and doctor. Be alert to changes
in your mood and your relations with others. Living with
emphysema can be difficult. Don’t be afraid top seek
counseling if you feel depressed or overwhelmed.
o Consider a support group. You may also want
to consider joining a support group for people
with emphysema. Although support groups
aren’t for everyone, they can be a good source
of information about new treatments and
coping strategies. And it can be encouraging to
be around other people who are meeting the
same challenges you are having.
• ISSUES AND TRENDS IN CHRONIC CARE
– Oxygen therapy
– Bullectomy
– Lung volume reduction surgery
– Lung transplantation
HYPERTENSION
Hypertension
Also called “High blood pressure”, is a serious
medical condition. It happens when the force of
the blood pumping through the arteries is too
strong.
• Normal blood pressure is below 120 systolic and
below 80 diastolic (120/80 mmHg).
• A blood pressure between 120/80 and 139/89 is

called “prehypertension.” This means that blood
pressure is higher than normal and at risk for
having high blood pressure.
• If blood pressure is 140/90 or higher most of the

time, it is considered high blood pressure.
Pathophysiology
Assessment
• ACTIVITY
- weakness
- fatigue
-shortness of breath
-elevated heart rate
-change in heart rhytm
-tachypnea; ahortness of breath with exertion

• CIRCULATION
- history of intermittent or sustained elevation of
diastolic or systolic blood pressure
-episodes of palpitations, diaphoresis
Note: POSTURAL HYPOTENSION, when present

may be related to srug regimen or reflect
dehydration or reduced ventricular function
• EGO INTEGRITY
-history of personality changes, anxiety,
depression, euphoria or chronic anger
-mood swings
-restlessness
-irritability
• PAIN
- angina
-severe occipital headaches

• RESPIRATION
- dyspnea associated with activity/exertion
-tachypnea
-orthopnea
-paroxysmal nocturnal dyspnea
-respiratory distress
-adventitious breath sounds
• SAFETY
-impaired coordination/gait
-transient episode of numbness, unilateral

paresthesias
-light headedness with position change

• CLASSIFICATION OF HPN
 Stage 1 high blood pressure
(essential hypertension) is 140-159
systolic or 90-99 diastolic
- in adult population, between 90%-95%

have essential HPN which has no
identifiable cause. It appeared to be
multifactorial, polygenic condition.
 Stage 2 high blood pressure
(hypertension) is 160 or higher systolic or
100 or higher diastolic
- characterized by elevations in blood

pressure with a specific cause such as
arterial disease, renal disease, certain
medications, tumors and pregnancy.
Hypertensive crisis (a medical
emergency) is when blood pressure is
above 180 systolic or above 110
diastolic.
Risk factors:
• Age
• Race - African-American adults are at higher

risk than white or Hispanic American adults
• being overweight or obese
• Sex
• Lifestyle
Medical Management
• pre-hypertension, will recommend lifestyle changes
to bring your blood pressure down to a normal
range. Medicines are rarely used for pre-
hypertension.
• Often, a single blood pressure drug may not be

enough to control blood pressure, and may need to
take two or more drugs.
Medical Management cont…
• It is very important to take the medicines
prescribed by the physician.
• different classes of drug are available and
all are suitable for lowering blood pressure:
 Diuretics
 Beta-blockers
 Calcium antagonists
Angiotensin-converting enzyme (ACE)
inhibitors
 Angiotensin receptor blockers.
Nursing Management
• Assess blood pressure at frequent imtervals;
know baseline levels. Note changes in
pressure that would require a change in
medication
• Note the apical and peripheral pulse rate,

rhythm, and character
Nursing Management cont…
• Assess symptoms such as nosebleeds, anginal
pain; shortneas of breath, alteration in vision,
speech or balance (vertigo); headaches or
nocturia
• Asses extent to which hypertension affected

the patient persinally, socially or financially
Nursing Management cont…
• Increasing knowledge
• Monitoring and managing potential

complication
• Promoting home and community based care
• Promoting compliance with self-care program

Health Education
 The lifestyle measures that are recommended by
experts and shown to reduce blood pressure are:
• Salt restriction
• Moderation of alcohol consumption
• High consumption of vegetables and fruits and low-
fat
• Reducing weight and maintaining it
• Regular physical exercise
• Quit smoking
STROKE - a sudden blockage or rupture of a blood
vessel in the brain thus resulting in interruption in
the blood supply to the brain, causing temporary or
permanent loss of movement, thought, memory,
speech, or sensation.
TYPES of STROKE
1. ISCHEMIC STROKE – Also known as

Cerebrovascular Accident or “Brain Attack” is a
sudden loss of function resulting from disruption of
blood supply to a part of the brain. (85% OF STROKE
CASES ARE USUALLY ISCHEMIC)
TYPES OF ISCHEMIC STROKES:
a. Large artery Thrombotic Stroke (20%)
b. Small penetrating Thrombotic Stroke (25%)
c. Cardiogenic Embolic Stroke (20%)
d. Cryptogenic Stroke (30%)
2. HEMORRHAGIC STROKE – are primarily caused by
intra cranial or subarachnoid hemorrhage. Hemorrhagic
strokes are caused by bleeding into the brain tissue, the
ventricles, or the subarachnoid space. (15% OF STROKE
CASES ARE USUALLY HEMORRHAGIC)
TYPES OF HEMORRHAGIC STROKE:

a. Intracerebral Hemorrhage (80%) – caused by
uncontrolled hypertension
b. Subarachnoid Hemorrhage
c. Arteriovenous malformation
d. Intracranial (cerebral) Aneurysm
3. TRANSIENT ISCHEMIC ATTACK (TIA) – Also
known as “ministroke” and is more accurately
characterized as a “warning stroke”. It is
caused by a clot; the only difference between
a stroke and TIA is that with TIA the blockage
is transient.
A. PROBLEMS EXPERIENCED BY PATIENTS:
1. Motor Loss
•Hemiplegia (Inability to move one side of the body)
•Hemiparesis (Partial inability to move)
•Ataxia (Unsteady gait)
•Dysphagia (Difficulty of swallowing)
2. Communication Loss
•Dysarthria (Difficulty speaking, forming words)
•Dysphasia (Impaired Speech)
•Apraxia ( inability to perform complex movement)
3. Perceptual Disturbances and Sensory Loss
• Visual-perceptual dysfunctions (Loss of Half
of the visual Field)
• Sensory Loss : Slight impairment of touch or
more severe with loss of proprioception;
difficulty in interpreting visual, tactile, and
auditory stimuli.
4. Cognitive Deficits
• Short and long term memory loss
• Decreased attention span
• Impaired ability to concentrate
• B. REVIEW OF PATHOPHYSIOLOGY
C. Specific Assessment focus and Medical Management
-Use of National Institutes of Health Stroke Scale – Enables the healthcare
provider to rapidly determine the severity and possible locations of stroke
GLASGOW COMA SCALE
NURSING ASSESSMENT
Acute Phase
Acute phase starts during the first three days. Nursing
assessment parameters:
• Change in level of consciousness or responsiveness, ability to
speak, and orientation
• Presence or absence of voluntary or involuntary movements of
the extremities
• Stiffness or ﬂaccidity of the neck
• Eye opening, comparative size of pupils and pupillary reactions
to light, and ocular position
• Color of face and extremities; temperature and moisture of skin
• Quality and rates of pulse and respiration
• Volume of ﬂuids ingested or administered and volume of urine
excreted per 24 hours
• Signs of bleeding
• Blood pressure maintained within normal limits
Postacute Phase
Assess the following functions:
• Mental status (memory, attention span, perception,
orientation, affect, speech/language).
• Sensation and perception (usually the patient
has decreased awareness of pain and temperature).
• Motor control (upper and lower extremity
movement); swallowing ability, nutritional and
hydration status, skin integrity, activity tolerance,
and bowel and bladder function.
• Continue focusing nursing assessment on
impairment of function in patient’s daily activities.
Medical Management
• Recombinant tissue plasminogen activator (tPA), unless contraindicated;

monitor for bleeding
• Anticoagulation therapy
• Management of increased intracranial pressure (ICP): osmotic diuretics,
maintain PaCO2 at 30 to 35 mm Hg, position to avoid hypoxia (elevate
the head of bed to promote venous drainage and to lower increased ICP)
• Possible hemicraniectomy for increased ICP from brain edema in a very
large stroke
• Intubation with an endotracheal tube to establish a patent airway, if
necessary
• Continuous hemodynamic monitoring (the goals for blood pressure
remain controversial for a patient who has not received thrombolytic
therapy; antihypertensive treatment may be withheld unless the systolic
blood pressure exceeds mm Hg or the diastolic blood pressure exceeds
120 mm Hg)
• Neurologic assessment to determine if the stroke is evolving and if other
acute complications are developing
D. Health Education in STROKE
• F.A.S.T. is an easy way to remember the sudden signs and symptoms
of a stroke:
Think "FAST" and do the following:
• Face. Ask the person to smile. Does one side of the face droop?
• Arms. Ask the person to raise both arms. Does one arm drift
downward? Or is one arm unable to raise up?
• Speech. Ask the person to repeat a simple phrase. Is his or her speech
slurred or strange?
• Time. If you observe any of these signs, call 911 immediately.
• Call your local emergency number right away. Don't wait to see if
symptoms go away. Every minute counts. The longer a stroke goes
untreated, the greater the potential for brain damage and disability.
• If you're with someone you suspect is having a stroke, watch the
person carefully while waiting for emergency assistance.
Treating Stroke Risk Factors
Quitting Smoking
• If you smoke or use tobacco, quit. Smoking can damage your
blood vessels and raise your risk of stroke and other health
problems. Talk with your doctor about programs and products
that can help you quit. Also, try to avoid secondhand smoke.
Secondhand smoke also can damage the blood vessels.
Following a Healthy Diet
• A healthy diet is an important part of a healthy lifestyle. Choose
a variety of fruits, vegetables, and grains; half of your grains
should come from whole-grain products.
• Choose foods that are low in saturated fat, trans fat, and
cholesterol.
Maintaining a Healthy Weight
• Maintaining a healthy weight can lower your
risk of stroke. A general goal to aim for is a
body mass index (BMI) of less than 25.
Being Physically Active
• Regular physical activity can help control many
stroke risk factors, such as high blood pressure,
unhealthy cholesterol levels, and excess weight.
• Talk with your doctor before you start a new
exercise plan. Ask him or her how much and
what kinds of physical activity are safe for you.
E. Behavioral Management in Stoke
Coping and Support

• Do not be hard on yourself.
• Get out of the house even if it's hard.
• Join a support group.
• Let friends and family know what you need.
• Know that you are not alone.
Communication challenges
• Practice will help.
• Relax and take your time.
• Say it your way.
• Use props and communication aids.
Issues and trends in Chronic care
Robot-Assisted Rehabilitation
Doctors have noted that robot-aided sensory motor training,
especially in upper extremity has been showing data consistent
with other controlled studies that demonstrate that more
activity leads to greater motor recovery and that such recovery is
sustained over the long-term and is limb and muscle group
specific.
Virtual Reality and Motor Imagery

One of the newest potential therapies currently under study is
virtual reality as a training tool in stroke rehabilitation. Virtual
reality is computer technology that simulates real-life learning
and allows for increased intensity of training while providing
augmented sensory feedback.
CHAPTER 7
Assessment of the Older Adult
FUNCTIONAL ASSESSMENT
Activities of Daily Living –
Tasks Typically Assessed with ADL

Assessment Tools
Eating
Dressing
Bathing/Washing
Grooming
Walking/ambulation
Ascending/descending stairs
Communication
Transferring (e.g., from bed to chair)
Toileting (bowel and bladder)
Instrumental Activities of Daily Living
(IADLs)
Advanced Activities of Daily Living (AADLs)

Functional Assessment
Activities of Daily Living –
Tasks Typically Assessed with ADL

Assessment Tools
Eating
Dressing
Bathing/Washing
Grooming
Walking/ambulation
Ascending/descending stairs
Communication
Transferring (e.g., from bed to chair)
Toileting (bowel and bladder)
Tasks Typically Assessed with IADL
Assessment Tools
Using the telephone
Taking medications
Shopping
Handling finances
Preparing meals
Laundry
Light or heavy housekeeping
Light or heavy yardwork
Home maintenance
Using transportation
Leisure/recreation
Physical Performance Measures
PHYSICAL ASSESSMENT
1. Circulatory Function
2. Respiratory Function
3. Gastrointestinal Function
4. Genitourinary Function
5. Sexual Function
6. Neurological Function
7. Musculoskeletal Function
8. Sensory Function
9. Integumentary Function
10.Endocrine and Metabolic Function
11.Hematologic and Immune Function
COGNITIVE ASSESSMENT
PSYCHOLOGICAL ASSESSMENT
1. Quality of Life
2. Depression
• Sadness
• Lack of enjoyment of previously enjoyed
activities
• Significant weight loss
• Sleep disturbance
• Restlessness
• Fatigue
• Feelings of worthlessness
• Impaired ability to think clearly or
concentrate
• Suicide ideation or attempt
SOCIAL ASSESSMENT
SPIRITUAL ASSESSMENT
OTHER ASSESSMENT: OBESITY
DEVELOPING AN INDIVIDUALIZED PLAN OF
CARE
CHAPTER 8
Medications and Laboratory Values
The older adult with medications requires
much more than pouring and
administering the drugs.
The Effects of Aging on Drugs
Normal Aging is associated with certain
physiological changes that can
significantly influence drug response.
Both pharmacokinetics and
pharmacodynamics play a role in how a
person will respond to a drug.
Pharmacokinetics – is the time course by
which the body absorbs, distributes,
metabolizes, and excretes drugs. It
speaks to how drugs move through the
body and how quickly this occurs.
Absorption – is defined as the movement

of a drug from the site of administration,
across biological barriers, into the
plasma. Although the rate of drug
movement through the body may
decrease with age, the extent of drug
absorption is least affected by age.
Distribution – is the movement of a drug

from the plasma into the cells.
With age, hepatic mass and hepatic
blood flow decrease. Hepatic Metabolism
also decrease with age.
Pharmacodynamics
Pharmacodynamics is the time course
and effect of drugs on cellular and organ
function. It what drugs do once they’re in
the body.
Drug-Related Problems in the Elderly
1. Adverse drug reactions (ADRs)
2. Food-drug interactions
3. Polypharmacy
4. Inappropriate prescribing
5. Non compliance
A.Adverse Drug Reactions – as “any
noxious, unintended, undesired effect of
a drug, which occurs at doses used in
humans for:
1. Prophylaxis
2. Diagnosis
3. Therapy
Types of ADRs
4. Drug-drug interactions – can be
defined as the alteration of the
pharmacokinetics or
pharmacodynamics of drug when taken
at the same time as drug.
Types of ADRs
2. Drug-disease interactions – are defined
as the worsening of a disease by a
medication.
B. Food-drug Interactions
Undetected food-drug interactions may
lead to serious morbidity and mortality in
the older adult.
C. Polypharmacy – many older patients
are prescribed multiple drugs, take over-
the-counter medications, and are often
prescribed additional drugs to treat the
effects of the medications that they
are already taking. The increase in the
number of medications often leads to
polypharmacy, which is defined as the
prescription, administration, or use of
more medications than are clinically
indicated in a given patient.
D. Inappropriate Prescribing – overall
there is no generalized rule for
prescribing drugs to the geriatric
population. Numerous studies indicate
that some prescribing patterns in the
elderly are inappropriate, such as no
indications for use of a drug,
dosages, and the possibility of drug
interactions or ARDs.
E. Compliance – although age alone does
not affect compliance, about 40% of
elderly persons do not adhere to their
medication regimen. It can be
encouraged by
1. Establishing a good relationship with
the patient
2. Providing education about possible
side effects
3. Providing clear instructions for how
the medication should be taken
4. Encouraging questions from the
5. Providing home nursing support as
needed.
POTENTIALLY INAPPROPRIATE
MEDICATIONS FOR GERIATRIC PATIENTS
There is a benefit/risk relationship
with the consumption of any medication.
The benefit of medication use is to
provide positive outcomes; the risk may
include unwarranted side effects.
LABORATORY VALUES
Due to physiologic changes,
laboratory results for older adults may
differ from those of younger adults.
LABORATORY VALUES
Medications to Avoid in the Elderly
1. Propoxyphene (Darvon) and
combination products – offers few
advantages over acetaminophen, yet
has the same adverse effects as other
narcotic medications.
2. Amitriptyline (Elavil),
chlordiazepoxide-amitriptyline
(Limbitrol), and perphenazine-
amytriptyline (Triavil) – strong
anticholinergic and sedation effects.
3. Diphenhydramine (Benadryl) – may
cause confusion and sedation; use in
smallest possible dose for emergency
reactions.
4. All barbiturates, except when used to
control seizures – highly addictive, more
adverse effects in the older adult.
5. Meperidine (Demerol) – may cause
confusion.
6. Short-acting nifedipine (Procardia and
Adalat) – potential hypotension and
constipation.
7. Clonidine (Catapres) – potential for
orthostatic hypotension and CNS adverse
effects.
reactions.
8. Mineral oil – potential for aspiration
and adverse effects, other options readily
available.
9. Estrogens only – lack of
cardioprotective effect in older women;
evidence of carcinogenic potential.
10. Nitrofurantoin (Macrodantin) –
potential for renal impairment; other
alternatives available.
11. Cimetadine (Tagamet) – CNS effects
including confusion.
reactions.
12. Indomethacin (Indocin and indocin
SR) – CNS adverse effects; other NSAIDs
available with fewer adverse effects.
13. Methocarbamol (Robaxin),
carisoprodol (Soma),chlorzoxaxone
(Paraflex), cyclobenzaprine (Flexeril),
oxybutynin (Ditropan) – anticholinergic
effects, sedation, weakness.
14. Short- acting dipyridamole
(Persantine) – orthostatic hypotension.
15. Methyldopa (Aldomet) and
Methyldopahydrochlorothiazide (Aldoril) –
may cause bdarycardia and exacerbate
depression in older adults.
Laboratory Values and Medication
Administration
1. Monitor compliance with medication
administration.
2. Check for therapeutic or toxic levels of
medication in the blood.
3. Evaluate the body’s ability to
metabolize medications.
Laboratory Values and Medication
Administration
4. Evaluate the need for medications to
treat a condition.
Whatever the case, it is important
that the nurse be aware of the
relationship between laboratory values
and medication administration.
Medication Blood Levels (Therapeutic
Blood Levels)
The amount of medication circulating
in the blood can be monitored for some
medications.
Blood Levels)
Some Medications Commonly Monitored
in the Elderly include:
1. Cardiac Medications
2. Antiepileptics
3. Certain antibiotics
Measuring medication blood levels is
important for monitoring the metabolism
of the medication so that the correct
dosage can be given, at the correct
intervals, to obtain the best results
without side effects or adverse reactions.
Blood Levels)
1. Metabolism of medications may be
altered in the elderly, so this concept
is an important one. Some medications
are toxic to the body if the level is too
high, and may be ineffective if the
level is too low.
2. Compliance – with medication
administration can also be monitored
through this type of testing.
Random Medication Levels in the Blood
1. Random Levels are not dependent
upon the administration time of the
medication. The blood level is drawn
when the order is received.
Trough Medication Levels in the Blood
1. Trough Levels – are dependent upon
the administration times of the
medication. The trough level is drawn at
the time that the blood level is expected
to be at its lowest: right before a dose is
due. An abnormally high trough level
indicates that the time between doses
should be adjusted (lengthened); an
Trough Medication Levels in the Blood
indicates that the time between
doses should be shortened.
Peak Medication levels in the Blood
Peak Levels are also dependent upon
the time of administration. This varies
according to the route of administration
and for different medications. An
abnormally high peak indicates that the
dosage needs to be reduced; an
abnormally low peak indicates that the
dosage should be increased. The peak is
typically drawn within a set time after a
dose given, and a trough follows right
Renal and Hepatic Function
Drugs are metabolized differently in
older adults. The kidneys and the liver
may not function well as in younger
persons. This can affect how medications
are cleared from the body and the
likelihood of side effects or toxic levels of
the medications. Certain medications
such as:
1. Aminoglycosides
2. Non-steroidal Anti-inflammatory Drugs
(NSAIDs)
3. Ace inhibitors
4. IV contrast materials (used for x-ray)
can also affect renal function in the
Renal and Hepatic Function
Drugs are metabolized differently in
older adults. The kidneys and the liver
may not function well as in younger
persons. This can affect how medications
are cleared from the body and the
likelihood of side effects or toxic levels of
the medications. Certain medications
such as:
1. Aminoglycosides
2. Non-steroidal Anti-inflammatory Drugs
(NSAIDs)
3. Ace inhibitors
4. IV contrast materials (used for x-ray)
can also affect renal function in the
Challenges to Successful Medication
Regimens for the Older Adult
5 Important Rights for the Elderly in the
Drug administration
1. Right Drug
2. Right Amount
3. Right Route
4. Right Times
5. Right Patient
Other Issues that Interfere with
Medication Administration
6. Function
7. Hearing
8. Vision
Other Issues that Interfere with
Medication Administration
4. Reading Ability
5. Memory/Cognition
6. Motivation
Common Test
1. Blood Urea Nitrogen (BUN) – this test is
used as a gross measure of glomerular
function and the production and
excretion of urea. Impairment of
kidney function will result in an
elevated BUN. The rate at which BUN
rises is influenced by the degree of
tissue necrosis and the rate at which
the kidneys excrete urea nitrogen.
2. Creatinine – is a substance removed
from the body by the kidneys.
Measurement of the creatinine level
will give a clue as to the function of
the kidneys.
ROLE OF THE NURSE REGARDING
LABORATORY VALUES AND MEDIACTIONS
1. Being aware of the routes of
elimination of medications and the
implications of aging on these routes.
2. Being aware of the effects of aging on
the typical signs and symptoms of
medication toxicity.
3. Maintaining knowledge of the signs of
medication toxicity in the older adult.
4. Drawing random, peak, and trough
medication levels correctly.
5. Knowing when to notify the prescriber
of an abnormal result.

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SECTION 1

Geriatrics – is often used as generic term

1. Social Gerontology – is concerned

4. Gerontological Nursing – falls within

Nurse Certification – is a formal process

• Gerontological Nurse Practioner

• Experience a high degree of

Core Competencies – Skills, Knowledge

1. Recognize one’s own and others’

Ageism – the negative attitudes toward

Roles of the Gerontological Nurse

Places for the Gerontogical Nurse to

AACN ESSENTIALS (1998)

5. Health promotion, risk reduction, and

6. Global health care

• Cultural factors influencing the

• Cultural factors, such as language, age,

• Access to culturally appropriate

• Reasons for these differences include

 Self-Esteem Disturbances (Risk for)

A state in which an individual who previously

Related factors: Internalization of ageist

A state in which an individual / group perceives

Example: Loss of the ability to drive a car, lack of

A state in which an individual is unable to modify

A state in which a individual experiences/at risk of

A state in which an individual/group experiences or

A state in which an individual experiences or at risk of

 Spiritual Distress (Risk for)

Ability to experience and integrate meaning and purpose

 Readiness for Enhanced Coping

 Health- Seeking Behaviors

 Readiness for Enhanced Knowledge

 Readiness for Enhanced Coping

 Ineffective Breathing Pattern

WELLNESS NURSING DIAGNOSIS

 Impaired Skin Integrity(Risk for)

A state in which individual experiences or at

 Ineffective Health Maintenance

A state in which an individual or group

 Readiness for Enhance Knowledge: Skin Care

 Disturbed Sensory Perception: Auditory

A state in which individual experiences or at

 Risk for injury

 Risk for injury

 Readiness for Enhanced Communication

 Ineffective Sexuality Pattern

 Readiness for Enhanced Knowledge:

• Antidepressants/anxiolytics: Fluoxetine (Prozac), sertraline (Zoloft),

• Antipsychotics: Haloperidol (Haldol), risperidone (Risperdal),

• Anticonvulsants: Valproic acid (Depakote), carbamazepine

• Stimulants: Methylphenidate (Ritalin)

• Occupational therapy may help persons with

• Lack of diagnosis is a major problem. Even in high-income countries, only one

Wear and tear theory

The Membrane Theory of Aging

1. Human Needs Theory – it was

2. Theory of Individualism – Jung’s

3. Stages of Personality Development

c. Personality development with