geriatric nurse

["Coping and Stress\u2003 CHAPTER 13\t 233 \u2002 Nursing Care Plan 13-1\u2003 Relocation Stress Syndrome Mrs. Mack, an 81-year-old woman, recently moved into Brookline Care Center. You observe that she looks sad. She spends most of her time alone, sitting in her room looking out the window. She repeatedly asks, \u201cWhy did they have to do this to me? I was happy where I was. I just wanted to stay there until I died.\u201d Mrs. Mack makes many demands of the staff and asks many questions. She complains that she has difficulty sleeping in strange surroundings with other people so close by. Mrs. Mack\u2019s chart reveals that she has a variety of health problems, including heart trouble and a history of high blood pressure. Until recently, she lived independently in her own apartment and required minimal help with getting to doctors\u2019 appointments and grocery shopping. More recently, she had become more forgetful, and her daughters were increasingly concerned about her safety and well-being living alone. Both daughters agreed that a care center would be most appropri- ate, and they found one near one of their homes that was reasonable in cost and that had a vacancy. They made arrange- ments for the move and notified the landlord before discussing the plans with Mrs. Mack. The daughters moved a few of her personal belongings with her, but many were sold or given to family members. NURSING DIAGNOSIS Relocation stress syndrome DEFINING CHARACTERISTICS \u2022\t Sad affect \u2022\t Apprehension \u2022\t Verbalization of concern about the move \u2022\t Increased dependency \u2022\t Increased demands and verbalization of needs \u2022\t Change in sleeping patterns PATIENT GOALS\/OUTCOMES IDENTIFICATION Mrs. Mack will verbalize an understanding of the reasons for her move, identify concerns about her new environment, and identify ways to cope with the change. NURSING INTERVENTIONS\/IMPLEMENTATION 1.\t Encourage Mrs. Mack to verbalize her feelings about the move. 2.\t Allow expressions of anger or frustration about the family\u2019s actions. 3.\t Encourage Mrs. Mack to discuss her feelings with her family. 4.\t Explain the reasons that necessitated the move. 5.\t Involve Mrs. Mack in decision making and care planning. 6.\t Maintain stable care assignments to build trust. 7.\t Encourage a positive attitude about change. 8.\t Offer opportunities to participate in social activities. 9.\t Encourage her family to bring in more valued personal belongings. 10.\t Consult a social worker or minister as appropriate to facilitate positive family interactions. EVALUATION Mrs. Mack\u2019s family has brought additional family pictures, some favorite pillows, and a lap robe that had been stored in a closet. They also purchased a small color television with special earphones for listening in bed. Mrs. Mack states, \u201cI still don\u2019t like it here, but I know that my family thinks it is best for me. They are trying to make it better, I guess.\u201d You will continue the plan of care. CRITICAL THINKING QUESTIONS 1.\t What behaviors would indicate that Mrs. Mack is adjusting to the change in living accommodations? 2.\t What additional nursing interventions can you identify that might help Mrs. Mack and her family reduce their stress? Get Ready for the NCLEX\u00ae Examination! \u2022\t Stress can result in behavioral changes. Excessive levels of stress are harmful. Key Points \u2022\t Individuals use a variety of coping mechanisms to deal \u2022\t Stress is a fact of life. with stress. \u2022\t Although the stressors may change throughout life, \u2022\t The effectiveness or ineffectiveness of these coping stress affects people of all ages. The major stressors of strategies is of concern to nurses. aging relate to losses. \u2022\t Loss of ability, loss of loved ones, loss of home, and \u2022\t Interventions that reduce stress and support positive many other losses are stressful to older adults, coping mechanisms can be beneficial. affecting physical and emotional status.","234\t UNIT III\u2003 Psychosocial Care of Older Adults Additional Learning Resources 4.\t An older adult tells the nurse that he feels \u201cstressed\u201d and asks what the nurse would recommend. What \u2002 Go to your Evolve website at http:\/\/evolve.elsevier would be the nurse\u2019s best response? .com\/Williams\/geriatric for the additional online resources. 1.\t \u201cSee your doctor for an antianxiety medication.\u201d 2.\t \u201cGet more sleep and try a glass of wine with dinner.\u201d Review Questions for the NCLEX\u00ae Examination 3.\t \u201cAre you aware of the tai chi class at the recreation center?\u201d 1.\t When assessing an older adult, the nurse suspects 4.\t \u201cJust let go of whatever is bothering you.\u201d an increased level of stress when observing which physiologic data? (Select all that apply.) 5.\t Which of the following are characteristics of depression 1.\t Increased urine production with retention and the older adult? (Select all that apply.) 2.\t Hyperventilation 1.\t Brief, but intense, episode of sadness 3.\t Warm hands and feet with sweating 2.\t May mimic physical symptoms of other disorders 4.\t Headache 3.\t Loss of interest in activities and events 5.\t Rapid pulse 4.\t Trouble concentrating 6.\t Elevated blood pressure 5.\t Increased energy level 7.\t Loss of appetite and nausea 6.\t An older adult tells the nurse that visiting the doctor is 2.\t What is the drug most commonly abused by older very stressful for her. What would be the nurse\u2019s best adults? response? 1.\t Cocaine 1.\t Suggest that she postpone the visit and go when 2.\t Marijuana she is more relaxed 3.\t Heroin 2.\t Tell the older adult that she needs to work on 4.\t Alcohol changing her attitude 3.\t Help her develop strategies for dealing with her 3.\t Which findings in the patient\u2019s history lead the nurse to concerns suspect alcohol abuse? (Select all that apply.) 4.\t Stress that it is important and she needs to go and 1.\t Poor nutrition get it over with 2.\t Liver disease 3.\t Financial problems 4.\t Strong family relationships 5.\t Peripheral neuropathy 6.\t Poor self-care 7.\t Repeated falls or accidents 8.\t Heart disease","Values and Beliefs chapter 14\u2003 Objectives http:\/\/evolve.elsevier.com\/Williams\/geriatric 1.\t Develop understanding of the impact of personal values 6.\t Discuss how culture and ethnicity affect older adults\u2019 and beliefs on everyday life. health beliefs and practices. 2.\t Identify values and beliefs commonly found in today\u2019s 7.\t Describe methods of assessing beliefs and values. older adult population. 8.\t Identify older adults at risk for experiencing problems 3.\t Discuss the impact of beliefs and values on the health related to values and beliefs. practices of older adults. 9.\t Identify selected nursing diagnoses related to values 4.\t Develop understanding of the relationship of values and or beliefs. beliefs to health practices. 10.\t Describe nursing interventions appropriate for older 5.\t Compare the spiritual practices of major religions as they adults who are experiencing problems related to values relate to death. or beliefs. Key Terms orthodox\u2002 (p. 236) religious\u2002 (p. 236) agnostic\u2002 (\u0103g-N\u014eS-t\u012dk, p. 239) ritual\u2002 (p. 240) atheist\u2002 (\u0100-th\u0113-\u012dst, p. 239) spiritual\u2002 (p. 239) cultural awareness\u2002 (K\u016cL-ch\u016dr-\u0103l a-W\u0100R-n\u011bs, p. 237) cultural competence\u2002 (K\u014eM-p\u011b-t\u011bns, p. 237) faith\u2002 (p. 235) Values and beliefs are uniquely human ideas that set system later in life. A person\u2019s values are a reflection us apart from other animals. As such, they are essential of his or her unique circumstances. Therefore, it is parts of our identity. Values and beliefs affect every nearly impossible to find two individuals with exactly aspect of our lives, including the experiences of life the same beliefs and values. Similar backgrounds and and death and the way we understand and manage experiences might result in shared values. Conversely, health. different circumstances and experiences may result in markedly different beliefs and value systems. For Older adults typically have an established system example, people sharing the same ethnic heritage may of values, goals, and beliefs that guides their decisions have similar values and beliefs that might differ sig- and choices. One\u2019s value and belief system is a product nificantly from the beliefs and values shared by another of a dynamic interplay of a variety of sociocultural ethnic group. People who spent their childhood and forces such as religion, family environment, culture, early youth in relative poverty are likely to view the and societal pressures and expectations. The founda- world quite differently from those who grew up with tion of the personal value system is set early in child- plenty of money. People brought up in one faith hood. Experts believe that most of our values are well community may share a great deal of beliefs, but established by the time we reach age 10. The idea that their views might be very different from the views the values that guide our lives for 80 or 90 years are shared by the members of another faith community. A established so early has significant implications for person raised in an environment of highly structured parents, educators, policy developers, and the larger family and kinship relationships is likely to view the society. world very differently from another person who was raised in an environment with more fluid family Values and beliefs develop in the context of a relationships. person\u2019s unique sociocultural environment. They are based on the messages communicated and reinforced Our beliefs and values impact our perception and by the family, culture, church, school, and media while experience of the world. We use them to attach meaning a person is growing up. The beliefs that are repeatedly to life events and to evaluate other people and their reinforced throughout youth are likely to have the actions. People have a natural tendency to view their greatest influence on the personal beliefs and value 235","236\t UNIT III\u2003 Psychosocial Care of Older Adults \u2022\t The Five Pillars of Islamic faith include (1) to proclaim \t the Shahadah (confession of the faith); (2) to perform the own personal beliefs and values as \u201cnormal\u201d or mandatory five daily prayers on time; (3) to fast during the \u201cnatural.\u201d Therefore, understanding people whose month of Ramadan, the ninth in the lunar calendar, from views are different from our own might be a challenge. dawn to sunset; (4) to pay Zakat religious tithes to the We are likely to be open and understanding when poor; and (5) to make a pilgrimage in Mecca, at least interacting with individuals and groups who share our once in a lifetime. views. We may be less understanding when interact- ing with people who have different views. This has \u2022\t There are no priests or ministers. Religious scholars or significant impact on the quality and nature of interac- teachers called Imams are regarded as authorities on tions between individuals. theological questions. Cultural Considerations \u2022\t Pork and its derivatives are prohibited. Alcoholic beverages and drug abuse are forbidden. \u2002 \u2022\t Modesty for women, particularly in dress, is highly Spirituality important. Many Muslim patients request that care be provided by women only. JEWISH SPIRITUALITY \u2022\t Judaism has four major branches: Orthodox, \u2022\t The body is washed at the time of prayer. Privacy is required for prayer. Conservative, Reform, and Reconstructionist. Highly Orthodox groups strictly follow ancient Talmudic law \u2022\t At death, the body is washed and then wrapped in a based on religious texts. Reformed and Conservative cotton sheet. A simple prayer is said for the soul of the groups accept many beliefs and practices but are less deceased person. Autopsy is allowed if necessary and\/or strict in other observances. required by law. Cremation is not allowed; the body \u2022\t A Jewish religious leader is a rabbi, and the place of should return to the earth in natural form. worship is the synagogue. \u2022\t Special dietary practices (Kosher) may require guidance LATINOS AND SPIRITUALITY from a rabbi or other authority. \u2022\t Family is valued over the individual. Family structure is \u2022\t Hygiene rituals, including circumcision and special bathing rituals, are part of tradition. generally patriarchal. \u2022\t The Sabbath starts at sundown on Friday and lasts until \u2022\t Many Latinos perceive cultural insensitivity and language sundown on Saturday. No work is to be done on the Sabbath. barriers as contributors to poor quality nursing and \u2022\t Ritual garb includes the tallit, or prayer shawl, which is medical care. the most authentic Jewish garment. It is a rectangular- \u2022\t Latino culture closely connects faith in the caregivers \t shaped piece of fabric with special fringes called tzitzit on with the ability to recover and heal effectively. They often each of the four corners. Also important is the yarmulke, verbalize that nurses need to address the person\u2019s total or kippah, which is a head covering worn to remind the life concerns and stressors, not just their physical faithful of God\u2019s presence and that there is something complaints. higher and greater than man. \u2022\t In times of illness, it is common for older adult Latinos to \u2022\t The Jewish religious calendar includes many religious seek out remedios (folk remedies), curanderos (traditional holidays. The most important ones include Hanukkah, Mexican healers), prayers, and over-the-counter Yom Kippur, and Passover. medications before they seek attention from organized \u2022\t Prayer is a part of daily life; it provides time for looking medical facilities. inward and is a means of examining one\u2019s relationship to God. Ritual prayer is connected to awakening, meals, and AFRICAN AMERICANS AND SPIRITUALITY bedtime. Groups of 10 men, a minyan, is desirable for \u2022\t Spirituality and religious practices are very important in prayer. A book of prayer called a siddur may be used to guide prayer. many families of African descent. \u2022\t Burial typically takes place within 24 hours of death. From \u2022\t Belief that illness is caused by failures of faith or by the the time of death until the burial, a guardian (shomer) stays with the deceased, reciting words from the Book of devil is common, and prayer is an important tool to deal Psalms. Embalming and cremation are not permitted. The with illness. body is dressed in plain white shrouds, regardless of \u2022\t Many different religions are practiced by the African- position. The casket must be made completely of wood American community. Be careful not to stereotype. so that the body should not decompose sooner than the Conduct careful assessment to determine the specific coffin. Seven days of mourning (shivah) begin immediately beliefs and practices of each individual. following burial. \u2022\t Some African Americans may seek to attend religious \u2022\t Organ transplantation is allowed but it may require the services several days a week or may desire frequent \t rabbi\u2019s approval. visits from their minister. Others, particularly Muslims, \t may observe dietary restrictions, including fasting and MUSLIM\/ISLAMIC SPIRITUALITY abstaining from pork products. \u2022\t Islam includes a wide variety of groups that vary in their AMERICAN INDIANS AND SPIRITUALITY level of orthodoxy. \u2022\t American Indians, who make up approximately 1% of the \u2022\t The emphasis of Islamic teachings is summed up in the U.S. population, are culturally diverse, represented by 517 holy book, the Koran (Qur\u2019an). The Koran should not be tribes and more than 150 languages. touched by anybody who is considered ritually unclean. \u2022\t More than half of American Indians live in the Southwest, but tribal groups can be found in most states. \u2022\t Some common beliefs that relate to life and death include a belief: (1) in a Creator or Great Spirit; (2) that all things in the world, living or not, have spirits; (3) that those","Values and Beliefs\u2003 CHAPTER 14\t 237 educated in sacred traditions are to pass them from one Developing understanding and appreciation for generation to the next; and (4) that interdependence with the values and beliefs of others might be a challenge. family and tribe is of high value. However, it is an essential component of therapeutic There is a strong focus on maintaining harmony between communication. To be effective communicators, nurses individuals and the universe. must develop awareness of their own values and \u2022\t For many American Indians, health and spirituality are beliefs, and the way they influence their perception inseparable. They may verbalize a need to be alone to of patients\u2019 experiences. Therapeutic communication practice cultural rituals or to seek guidance from the requires openness and ability to listen to the patients community elders to maintain harmony of mind, spirit, without judgment. This requires an ongoing reflective and body. evaluation of own beliefs. Nonjudgmental communi- \u2022\t Older adults are to be respected for their age and cation requires much patience and excellent commu- wisdom. nication skills. EURO-AMERICANS AND SPIRITUALITY Home Health Considerations The influence of Christianity began during the height of the Roman Empire and has continued for over 2000 years. The \u2002 history of Christianity includes multiple splits resulting in a development of numerous Christian denominations with beliefs Cultural Competence and religious rules that differ and even contradict each other. While Christian churches remain separate and distinct, interac- Nurses must be aware of patients\u2019 cultural values and beliefs tion between denominations has improved somewhat since to provide care to an increasingly diverse patient population. the 1960s when the leaders of various denominations started Research shows that the patients who receive culturally con- \u201cecumenical\u201d outreach to improve understanding between gruent care are more likely to adhere to treatment, have better Christian groups. The secular nature of modern society has outcomes, and are more likely to use healthcare services. somewhat diminished some real or perceived animosity Therefore, cultural awareness and competence are manda- between churches, but old rivalries may still be alive in some tory components of professional nursing standards. Cultural religious communities. competence in nursing can be defined as a set of behaviors that includes understanding the impact of cultural values and Christian denominations include Catholics, Orthodox, beliefs on human experiences, while maintaining awareness of Episcopalians, Anglicans, Lutherans, Methodists, Presbyterians, own cultural values and their effect on the perception of self Congregationalists, Baptists, Mormons, Fundamentalists, and and others. Cultural competence requires cultural awareness, \u201cnondenominational\u201d Christians. There are many subgroups which is knowledge and appreciation of unique features of a within each of denominations. Specifics regarding each group\u2019s cultural group such as history, customs, artistic expressions, beliefs and practices should be sought from the patient\u2019s min- cuisine, and health practices. The nurse who possesses\t ister or clergy. the necessary level of cultural competence is more likely to \u2022\t Although each Christian church has unique perspectives, successfully establish and maintain therapeutic relationships, and deliver highly effective care reflective of the patients\u2019 some things that most Christians believe include: unique needs. \u2022\t God is the creator of everything seen and unseen. \u2022\t Christ is the son of God and is one with God in the Acquisition of cultural knowledge is an ongoing process. The nurse must become familiar with resources that can be trinity. used to facilitate that process. The following are examples of \u2022\t Christ suffered, was crucified, died and was buried, websites that contain information on cultural competence: \u2022\t www.culturediversity.org\/ rose from the dead, and ascended into heaven. \u2022\t www.xculture.org\/training\/overview\/cultural\/ \u2022\t Christ will return to judge the living and the dead. assessment.html Those who repent will have their sins forgiven and can \u2022\t www.tcns.org\/ be saved. \u2022\t Most Christian churches have a specified and hierarchical Developing understanding of the impact of values and organizational structure. beliefs on one\u2019s perceptions of self and others is not \u2022\t Clergy are typically educated in the tenets of the specific easy. It requires ongoing commitment to personal and faith and then \u201cordained\u201d as a minister of the faith. professional growth. The most effective way to develop \u2022\t Most have an organized set of rituals or sacraments \t appreciation and understanding of diverse beliefs and to address life events such as marriage, holidays, \t values is through education, which can be gained death, etc. through reading, participating in professional devel- opment activities, studying academics, and interacting Differences in beliefs and values are a common source with individuals of diverse backgrounds. Patient of communication problems. Statements such as \u201cHe teaching and positive interactions can help people just doesn\u2019t understand me\u201d or \u201cI just don\u2019t under- understand the way their values and beliefs influence stand her\u201d usually indicate a conflict in beliefs or their perception and management of health. Developing values. Think about how often you have heard this awareness is usually the first step toward positive parents say this about their children and vice versa, or change. Nurses who develop an understanding of the the number of times a member of one ethnic or reli- beliefs and values of the groups commonly encoun- gious group says it about another. Consider the times tered in their practice can facilitate this change by nurses say this about a patient of a different age, race, or background.","238\t UNIT III\u2003 Psychosocial Care of Older Adults Some of these attitudes might change as Baby Boomers enter late adulthood. Baby Boomers grew up helping their clients adopt healthy behaviors and by in a more affluent world and are more likely to value teaching them to manage their health resources. material possessions and spend rather than save. This is likely to result in increased fear of retirement and COMMON VALUES AND BELIEFS older adults remaining in the workforce. Research OF OLDER ADULTS shows significant financial discrepancies between Baby Boomers, depending on race and gender. The older adult population is as diverse as younger age groups. However, they do share some values and INTERPERSONAL VALUES beliefs based on the shared experiences of their genera- Today\u2019s older adults were raised in an era when inter- tion. The population of people who are currently age personal communication was more formal. Some of 60 years or older have developed their value system in them may expect that caregivers address them for- a world that was very different from today\u2019s world. mally, using their last name. Moreover, they grew up For example, they spent most of their working life valuing respect and obedience to older adults and may before the Internet and media explosion and long expect to be treated with deference by younger care- before mobile communication devices became a man- givers. This also applies to their relationship with their datory accessory. In those days, there was less drive to family members. Older people often cannot under- understand diversity, and following the rules of the stand why their families do not automatically accept mainstream society was desirable. Therefore, many of what they say and follow their directions. This might their beliefs may differ significantly from the beliefs lead to misunderstanding and conflict. Nurses are held by younger generations. Intergenerational differ- often called on to act as mediators when conflicts arise ences in the values and beliefs may lead to misunder- or to provide support to an older person who feels standing and conflict. As the nursing workforce rejected or misunderstood by his or her children. becomes increasingly diverse and as more young nurses enter the workforce, the differences in beliefs CULTURAL VALUES may challenge nurses\u2019 ability to establish therapeutic The U.S. society is becoming increasingly diverse. relationship with their aging patients. As trusted pro- Groups that were traditionally considered minorities fessionals, nurses must carefully evaluate the impact are growing across all age groups, including the aging of the beliefs of aging patients and their own beliefs population. The proportion of people belonging to before they plan and implement care. Failure to do so minority groups who are at least 65 years of age will can jeopardize therapeutic relationships with patients increase from 20% in 2010 to 42% in 2050 (Vincent & and result in care that does not meet the patients\u2019 Velkoff, 2010). Nurses providing care to the aging pop- unique needs. ulation must be able to provide care to this increas- ECONOMIC VALUES ingly diverse group. Many of today\u2019s older adults grew up or were brought up by parents affected by the Depression of the 1930s. Cultural values and beliefs unite families, neighbor- They were taught to be frugal and mindful of resources. hoods, and communities. Shared cultural values define Consequently, they value financial independence and an authority structure, establish norms for language may have difficulties accepting financial assistance or and communication, and establish a basis for decision handing over financial management to another person. making and lifestyle choices. Historically, U.S. society They might express concern over the cost of care, and was shaped by many foreign immigrants who arrived may delay seeking help or even refuse to use health- in search of opportunity and a better life. In addition, care services until they are seriously ill if they fear that U.S. cultural identity is still influenced by a troubled the care might be too costly. They might refuse to buy history of slavery and warfare with its native citizens. medications, or take less than the amount prescribed The ever-increasing cultural diversity creates a vibrant in order to save money. and dynamic society, but it also creates many oppor- tunities for prejudice and misunderstanding. Some older adults save or hoard items, including items that present health hazards because they value Although most people express a dislike for any saving rather than wasting. This may be a problem for form of prejudice or segregation, these problems still older people who need to be placed in nursing homes exist. The health status of minority groups still lags because they will have a difficult time parting with behind that of the mainstream groups. In addition, their possessions. When living in a community, clutter members of minority groups are still experiencing (excess items) in their homes can expose older adults difficulties accessing healthcare services and are to safety hazards and multiple health risks. Some less likely to receive culturally congruent care. This is older people may be dismayed when nurses or family partially a result of discrimination by the dominant members throw away food or medical supplies and culture, but it may be affected by the need of may attempt to retrieve these items, particularly when minority groups to maintain their own uniqueness and they are left alone. cultural practices.","Values and Beliefs\u2003 CHAPTER 14\t 239 Many of today\u2019s oldest adults were brought up at New immigrants experience a period of \u201cculture the times when organized religion played an impor- shock\u201d when entering a new cultural environment tant role in society. Organized religion may have where their historic values and practices differ from played an important role in the formulation of their the dominant culture. Response to this experience individual values and beliefs. Regular attendance at varies widely. Some will quickly assimilate into the places of worship, although highly valued by many dominant society and modify or even suppress their older adults, has been declining in recent years. This cultural identity. Others may hold to their cultural may, in part, result from transportation problems or uniqueness and resist assimilation into the larger safety concerns that make regular attendance difficult. society. They may isolate themselves into an enclave Many older adults experience severe spiritual distress for mutual support and actively resist assimilation. when they are no longer able to worship regularly Still others try to find a middle ground, neither isolat- because of illness, hospitalization, or relocation to an ing nor fully assimilating. Members of the same family institutional setting. This is particularly important in may experience different reactions from others, leading the context of nursing care. At times of personal and to intra-family culture conflict. health crises, many older individuals have an increased need to connect with their spiritual communities. Not Many older adults still identify more with their being able to do so may adversely affect their sense of ethnic group or country of origin than with the domi- well-being. nant society. At times of stress, individuals tend to Older adults may have difficulties understanding revert to beliefs, values, and sometimes language contemporary changes in the structure of organized established during childhood. Therefore, nurses must religions, especially the current trend toward coopera- be versed in providing culturally congruent care tion among religious groups. Many older adults were to older adults. Many healthcare organizations and taught the value of their own beliefs and are suspicious agencies offer mandatory training to their clinical of religions other than their own. The interdenomina- staff. Nursing professional organizations offer courses tional or nondenominational services that are provided and other resources to support development of cul- in many institutional settings may not meet the needs tural competencies. Transcultural Nursing Society of older adults. They may have developed closeness to offers several levels of certification in transcultural a specific spiritual adviser and may be uncomfortable care. All these resources can help nurses develop if this person is unavailable. Spiritual counseling often understanding of many nuances of culturally congru- explores intimate secrets and fears. Older adults may ent nursing care. be unwilling to interact with a stranger, even if this SPIRITUAL OR RELIGIOUS VALUES person is a qualified minister. Increased participation Spirituality is a deeply personal experience of connect- of women in the ministry upsets some older people edness with a higher entity. Some individuals find who believe in traditional delineation of gender roles, their spirituality within a specific religious community, and they may reject female religious officials. although others have more fluid approach and ground Many older adults continue to pursue traditional their spirituality in social and\/or natural laws. As a religious practices, which have changed over time. For personal experience, it can vary significantly from one example, many older adult Catholics will not eat meat person to another. Some people identify themselves as on Fridays, although that is no longer required except religious, while others state that they are agnostics or through designated periods. Similarly, older adult atheists. Although an atheist does not believe in the Jews may continue to value orthodox dietary and existence of god, an agnostic is a person who neither hygiene practices, although many younger Jews have believes nor denies the existence of god. It is a mistake accepted less rigid standards. If the person has per- to assume that nonreligious individuals are not spiri- sisted in these practices over a lifetime, change is tual. People who refuse to identify with religious highly unlikely. In these cases, nurses and the health beliefs may merely indicate that they do not subscribe care system must be flexible enough to enable these to beliefs of recognized religious systems. Nurses must persons to maintain their beliefs while maintaining be aware of the personal nature of spirituality and adequate hygiene and nutrition. This might require respect patients\u2019 choices. adjustment to care plans to reflect the older adults\u2019 beliefs. Even though there are many individual differ- Spiritual beliefs can motivate or inhibit an indi- ences, Baby Boomers who are currently entering late vidual\u2019s desire to take certain actions. In addition, adulthood were likely raised with some organized reli- spiritual beliefs have huge impact on the way one gious beliefs. They are also likely to have changed to experiences life events, including those related to lesser traditional spiritual practices, which are more in health. They can inspire pleasant emotions such as keeping with a secular world. wonder, love, hope, and trust, but they can also insti- The need for spiritual connections grows as a person gate unpleasant emotions such as hatred, anger, fear, ages and death nears. Spiritual beliefs can be a source guilt, and despair. Individuals usually build their of strength, and even people who did not seem to place value system and set their priorities based on their spiritual beliefs.","240\t UNIT III\u2003 Psychosocial Care of Older Adults FIGURE 14-1\u2003 Residents attend a religious service at a nursing center. FIGURE 14-2\u2003 Tradition in thought\u2014spirituality in Judaism. (From Kostelnick C: Mosby\u2019s textbook for long-term care nursing assistants, ed 7, 2015, St. Louis, Mosby.) practices often prefer to be hospitalized or live in institutional settings operated by their preferred reli- a high value on their spiritual development when they gious denomination, if these are available in the were younger often see a need to seek spiritual guid- community. ance when they get older (Figure 14-1). People who have rejected organized religion throughout the major- Complementary and Alternative Therapies ity of their life might change their mind and vice versa. Therefore, incorporate spiritual assessment into the \u2002 assessment of an older person, and offer access to spiri- tual care when needed. Older adults may embrace or Prayer and Meditation reject spiritual care; respect their choices and do not impose your values and beliefs upon them. Prayer is a religious ritual used in many religions to communi- cate with the higher power as defined by an individual\u2019s beliefs. Decisions regarding the end of life are greatly influ- It can be ritualized and structured, or free and informal. Many enced by patients\u2019 spiritual beliefs and personal value times, prayers are accompanied by other religious rituals and systems. Many older adults wish to have a spiritual symbols such as candles, incense, beads, etc. Prayer can be advisor available for guidance when making decisions incorporated into the plan of care as a complementary therapy about serious health matters. Caregivers must respect designed to promote the patient\u2019s spiritual needs. the patients\u2019 decisions based on religious beliefs, even when they are in conflict with caregiver\u2019s beliefs and Similarly to prayer, some individuals like to use meditation values. Survival may be less important to an older to experience a state of mind that provides them with relax- person than the violation of long-held beliefs. Coherent ation, stress and anxiety relief, or better understanding of self. older people have the right to make informed choices Meditation has many forms, some of which are associated with and to have them respected. specific religious practices although others are based on non- religious principles. The value of meditation in pain manage- Religious rituals are formal and observable ceremo- ment is well-documented and is often used as a part of pain nies used to affirm faith and sense of belonging to a management. Research has also shown that meditation can spiritual community. They are found in every faith and create a relaxation response and has been demonstrated to include rituals such as prayers, chanting, cleansing, reduce anxiety. anointing, and singing religious music. They often involve the use of symbolic objects such as icons, Many older adults reach the end of life at peace with them- menorahs, rosaries, amulets, medals, and holy water. selves. It is common for an older adult to say, \u201cI\u2019m ready to Religious texts such as the Bible, Koran, Torah, Vedas, go. I\u2019ve led a good life, not perfect, but I\u2019m ready to meet my and Book of Mormon are essential to the practices of maker.\u201d Others may not be as peaceful but accept the inevi- their respective religions (Figure 14-2). Many older tability of death. However, some older people will experience adults find great comfort in these texts, often memoriz- considerable anxiety and distress as the end of life approaches. ing large segments. Older adults who are unable to The experience and reaction to the end of life is not related\t read because of the changes associated with aging or to a person\u2019s age. It is often related to a person\u2019s evaluation illness find comfort in the mere presence of these of their life. They may experience a sense of guilt because of valued tenets of their faith. Often, the family or spiri- unresolved long-standing conflict with important people in their tual support person will provide these symbols and life or the belief that they did not tie up their personal affairs. texts if the older person or nurse requests them. Some This may lead to considerable spiritual distress at the end\t religious-sponsored institutions provide them rou- of life. Spiritual distress is characterized by hopelessness and\/ tinely. Individuals with strong religious values and or failure to see one\u2019s life in positive light. People experiencing spiritual distress are often fearful or angry. To be open to the spiritual needs of others and work effectively with patients experiencing spiritual distress, the nurse should explore his or her own spiritual feelings and beliefs (see Critical Thinking box and Box 14-1).","Values and Beliefs\u2003 CHAPTER 14\t 241 Box 14-1\u2003 SPIRIT Mnemonic for Spiritual Assessment Box 14-2\u2003 Risk Factors Related to Problems with Values and Beliefs in Older Adults S: Spiritual belief system (religious affiliation) P: Personal spirituality (personal belief system) \u2022\t Major life stressors such as severe illness or I: Integration into a spiritual community (sources of impending death support) \u2022\t A recent significant loss or change in role R: Ritualized practices (daily practices, restrictions, and \u2022\t Values and\/or beliefs different from those of caregivers their significance) or the dominant cultural values I: Implications for medical care (spiritual aspects \u2022\t Removal from a familiar spiritual support system \u2022\t Loss of financial independence incorporated into care) T: Terminal event (end of life) NURSING DIAGNOSIS From Maugans TA, as presented in Larson K: The importance of spiritual \u2002 assessment: one clinician\u2019s journey. Geriatr Nurs 24(6):370\u2013371, 2003. Spiritual distress Critical Thinking NURSING GOALS\/OUTCOMES IDENTIFICATION \u2002 \u2002 Spiritual Assessment for Nurses \u2022\t Reflect on your spirituality. Do you consider yourself to be The nursing goals for older adults suffering from spiri- tual distress are to (1) identify and verbalize sources spiritual or religious? Why or why not? of value conflicts; (2) specify the spiritual assistance \u2022\t Develop a list of your values with the most important ones desired; (3) discuss values and beliefs regarding spiri- tual practices; and (4) express feelings of spiritual on top. Reflect on why certain values are more important comfort. than others. \u2022\t Reflect on what gives meaning to your life. NURSING INTERVENTIONS\/IMPLEMENTATION \u2022\t Identify your spiritual and\/or religious practices. \u2022\t Reflect on how your spiritual and\/or religious beliefs impact \u2002 your daily life, including your professional life. \u2022\t Identify the ways your spiritual and\/or religious beliefs \t The following nursing interventions should take place may affect your perception and response to patients\u2019 in hospitals or extended-care facilities: spiritual needs, especially if they are in conflict with your 1.\t Determine whether there are special spiritual beliefs. practices and\/or restrictions. Identify the unique NURSING PROCESS FOR SPIRITUAL DISTRESS spiritual needs of older adults. Even though aca- demic and professional nursing resources identify \u2002 and describe the common beliefs and practices of the major denominations, always clarify each ASSESSMENT\/DATA COLLECTION individual\u2019s interpretation of and compliance with these beliefs and practices. This is particularly \u2002 important if the religion requires or prohibits certain diets or health behaviors. Whenever possible, allow Ask the following questions when conducting cultural older adults to continue practices and rituals as long and spiritual assessment: as they do not interfere with health maintenance. If \u2022\t What is your cultural background? there is a conflict between spiritual values or prac- \u2022\t What is your first language? tices and health needs, consult with an authority \u2022\t Are you comfortable discussing your treatment in of the specific church to identify acceptable strate- gies or compromises. Failure to consider the older English? adult\u2019s spiritual beliefs can result in anger, despon- \u2022\t Do you need support from your family members, dency, and noncompliance with the plan of care. 2.\t Identify significant people who provide spiritual friends, or spiritual advisors when making deci- support. Most religions recognize certain people as sions about your treatment? spiritual leaders or guides who assist others to learn \u2022\t How does your condition affect your life? and practice the beliefs of the specific faith. Priests, \u2022\t What traditional remedies have you used or would rabbis, ministers, deacons, and religious sisters like to use to treat your condition? are commonly recognized as spiritual counselors or \u2022\t Are you a member of a religious or spiritual chaplains in institutional settings. These individu- group? als are the recognized authorities who are trained \u2022\t Are there any cultural or religious practices you to provide counsel to their own members and often would like to pursue while you are in our care? to members of different faiths. Many older adults \u2022\t Would you like to talk to your spiritual or religious have a special closeness to a specific spiritual coun- adviser? selor whom they trust and will appreciate a call or \u2022\t Are there any foods that your religion forbids? visit from their regular spiritual advisor or minister, \u2022\t Are there any religious books or symbols that you particularly when hospitalized or in danger of would like to have with you? \u2022\t How can we (nursing staff) support your religious practices or your spiritual needs? \u2022\t Box 14-2 provides a list of risk factors for alterations in values and beliefs in older adults.","242\t UNIT III\u2003 Psychosocial Care of Older Adults FIGURE 14-3\u2003 The main place of worship for Muslims, the mosque. (From deWit SC, O\u2019Neill P: Fundamental concepts and skills for death. If needed, contact these individuals or request nursing, ed 4, 2013, St. Louis, Saunders.) that the family initiates the contact. Do not treat it as a nonessential task, because many people gain as person wishes to meet with a spiritual adviser or to much sustenance from spiritual counsel as they do perform religious rituals, he or she should have the from medical treatment. In addition to providing opportunity to do so. This may require planning counsel to the older adult, the spiritual counselor so that no interruptions (e.g., cares or treatments) can help the family meet their spiritual needs during interfere with the religious activity. stressful situations. A trained chaplain or spiritual 7.\t Encourage contact with a spiritual counselor in counselor can also act as a liaison among the patient, times of crisis. Privacy is important in times of family, and clinical staff by interpreting spiritual spiritual crisis, such as the loss of a loved one or practices and concerns. imminent death. Severe grief can lead to spiritual 3.\t Determine whether there is any way nurses can distress. Contact with a spiritual counselor can help aid older adults in meeting their spiritual needs. older adults work through feelings of anger, resent- Conduct an assessment to determine whether any ment, or ambivalence toward their spirituality. The assistance is required to enable older adults to meet spiritual counselor can provide support to dying their spiritual needs. Nurses are often asked to persons and can assist the families in their time of assist older adults in spiritual practices by contact- grief. Pay special attention to spiritual rituals related ing spiritual advisers, providing spiritual articles, to death such as confession, communion, or anoint- or facilitating religious rituals. ing. Be aware of acceptable religious practices before 4.\t Provide opportunities for the older adult to express preparing the body after death. his or her spiritual needs and concerns. Listen, in The following interventions should take place in the a nonjudgmental manner, to whatever the older home: adult wishes to verbalize. When problems or con- 1.\t Make arrangements that allow older adults to cerns exist, it often helps to verbalize them to maintain religious practices. Arrange for transpor- someone else. In most cases, the speaker does not tation to the place of worship (Figure 14-3). Many want to have a mutual conversation, but rather religious organizations can find rides for members wants to be unburdened or get his or her fears out who are not able to walk or drive. If this is not pos- in the open so he or she can begin to deal with them. sible because of severe health problems or immobil- Help the person explore issues rather than stopping ity, arrange a visit from a spiritual adviser. the thoughts or providing reassuring platitudes. 2.\t Use any appropriate interventions that are used in Life review or reminiscence may be helpful in the institutional setting (Nursing Care Plan 14-1). aiding the older adult through these doubts and concerns. 5.\t Determine spiritual objects that have meaning to the older adult; obtain these if possible. Place the objects that are symbolic of faith where they can be seen or touched by older adults; they should not be hidden or put away in a drawer. All religious items should be shown due respect by all caregivers. Even if the caregiver is of a different faith, it is important to recognize and respect the symbols of another person\u2019s religion. 6.\t Provide opportunities for spiritual guidance with respect for privacy. Because spiritual practices often include sharing of private thoughts and fears, provide older adults with opportunities to be alone to pray or meditate if desired. A chapel or quiet room free from distractions is desirable. If the \u2002 Nursing Care Plan\u2002 14-1\u2003 Spiritual Distress Mr. Quinn, age 78, has attended a Christian church regularly and has expressed a strong belief in a \u201cmerciful God.\u201d A week ago, he learned from his doctor that he has terminal cancer and has approximately 3 months to live. After talking to the doctor, he went to the chapel and cried. Since then, he has spent a great deal of time in his room reading the Bible. He often verbalizes statements questioning the value of prayer and states that \u201cGod hasn\u2019t shown me any mercy, but I probably have to suffer for all I\u2019ve done wrong in my life.\u201d","Values and Beliefs\u2003 CHAPTER 14\t 243 \u2002 Nursing Care Plan\u2002 14-1\u2003 Spiritual Distress\u2014cont\u2019d NURSING DIAGNOSIS Spiritual distress DEFINING CHARACTERISTICS \u2022\t Anger \u2022\t Verbalization of hopelessness and purposelessness \u2022\t Verbalization of lack of self-forgiveness \u2022\t Expresses lack of courage, lack of acceptance \u2022\t Expresses lack of serenity \u2022\t Verbalization of feelings of guilt PATIENT GOALS\/OUTCOMES IDENTIFICATION Mr. Quinn will recognize that illness places stress on a belief system and will express feelings of spiritual comfort. NURSING INTERVENTIONS\/IMPLEMENTATION 1.\t Listen to Mr. Quinn\u2019s concerns and feelings in a nonjudgmental manner. 2.\t Request a visit from the hospital chaplain (if desired, contact a personal minister). 3.\t Provide privacy for spiritual counseling and sacraments. 4.\t Keep the Bible and a prayer book readily available. 5.\t Assist Mr. Quinn to the chapel as requested. EVALUATION Mr. Quinn visits the chapel daily and has a weekly visit with his minister. After each visit, he appears calmer, stating that \u201cI still don\u2019t know why this is happening to me, but I\u2019ll just have to put my trust in God.\u201d You will continue the plan of care. CRITICAL THINKING QUESTIONS 1.\t What type of verbal or nonverbal responses from the nurse would best demonstrate nonjudgmental acceptance of Mr. Quinn\u2019s feelings? 2.\t What could the nurse do if Mr. Quinn states, \u201cI don\u2019t believe in a merciful God anymore\u201d and refuses visits from a chaplain or other spiritual counselor? Get Ready for the NCLEX\u00ae Examination! Review Questions for the NCLEX\u00ae Examination Key Points 1.\t The nurse cares for an older adult in an extended-care facility. Which statement indicates possible spiritual \u2022\t Everyone\u2019s values and beliefs are unique. They are a distress? product of the individual\u2019s culture, education, religion, 1.\t \u201cI made some mistakes, but my life turned out pretty and society. well.\u201d 2.\t \u201cI feel that God abandoned me and that I will die all \u2022\t These values and beliefs form the basis of the older alone.\u201d person\u2019s choices, perceptions, and behaviors. 3.\t \u201cMy relationship with my children has not been perfect, but I think we finally managed to iron our \u2022\t The values and beliefs held by older adults may differences.\u201d significantly differ from those held by younger 4.\t \u201cMy husband died 19 years ago and is waiting for individuals. me to join him.\u201d \u2022\t If not identified, these differences can result in 2.\t The nurse observes an older adult who saves misunderstandings, confusion, and conflict between unopened crackers, jelly, and juice packages from the older adults and their families or younger health care meal tray. What does this behavior most likely indicate? providers. 1.\t That the person would like an additional snack 2.\t That the person is frugal and does not want to \u2022\t Nurses can reduce problems related to differences in waste good, usable items values and beliefs by openly communicating with older 3.\t That the person has problems with hoarding that adults and by gaining more in-depth information needs to be evaluated regarding social, spiritual, and cultural diversity. 4.\t A habit that means nothing in particular Additional Learning Resources \u2002 Go to your Evolve website at http:\/\/evolve.elsevier .com\/Williams\/geriatric for the additional online resources.","244\t UNIT III\u2003 Psychosocial Care of Older Adults 3.\t An older Latino patient wants his family to bring folk 5.\t The nurse is caring for a female patient who identifies remedies to the long-term care facility. What is the herself as an atheist. Which statement made by the nurse\u2019s best response? nurse indicates that nurse understands the nature of 1.\t Tell them that these are harmful and to be avoided. spirituality? 2.\t Remind them that only the physician can order 1.\t \u201cDo you have any spiritual practices we can assist treatments. you with?\u201d 3.\t Encourage them to bring whatever is requested. 2.\t \u201cWould you like me call our on-call priest to see if 4.\t Identify the benefits and risks of these remedies. he can help you?\u201d 3.\t \u201cWould you like me to remove Gideon\u2019s bible from 4.\t Identify two of the five Islamic Pillars of Faith: your room?\u201d 1.\t ________________________________________________ 4.\t \u201cI guess you won\u2019t be needing services of our 2.\t ________________________________________________ spiritual care department.\u201d","End-of-Life Care chapter 15\u2003 Objectives http:\/\/evolve.elsevier.com\/Williams\/geriatric 1.\t Discuss personal and societal attitudes related to death 5.\t Identify cultural and spiritual considerations related to and end-of-life planning. end-of-life care. 2.\t Identify factors that are likely to influence end-of-life 6.\t Describe nursing assessments and interventions decision making. appropriate to end-of-life care. 3.\t Explore caregiver attitudes toward end-of-life care. 7.\t Discuss the role of the nurse when interacting with the 4.\t Discuss the importance of effective communication at the bereaved. end of life. 8.\t Describe the stages of grief. Key Terms hospice\u2002 (H\u014eS-p\u012ds, p. 249) morgue\u2002 (m\u014frg, p. 258) anorexia\u2002 (\u0103n-\u014f-R\u0114K-s\u0113-\u0103, p. 255) palliative\u2002 (P\u0102L-\u0113-\u0103-t\u012dv, p. 249) cachexia\u2002 (k\u0103-K\u0114K-s\u0113-\u0103, p. 255) Cheyne-Stokes\u2002 (ch\u0101nst\u014dks, p. 255) ethical dilemmas\u2002 (p. 247) During the seventeenth century, the poet John Donne damage. Eventually, the individual will run out of wrote, \u201cNo man is an island \u2026 any man\u2019s death dimin- recuperative reserve and die. ishes me, because I am involved in mankind; and therefore never send to know for whom the bell tolls; DEATH IN WESTERN CULTURES it tolls for thee.\u201d In those days, a death was acknowl- edged by a solemn ringing of church bells, much the The experience of death in Western cultures is a reflec- way bells are rung at many funerals today. Death was tion of an ethnocultural climate that emphasizes indi- feared, but it was perceived as an inevitable part of vidualism and self-reliance. A person\u2019s family may not life. Infants, children, and young adults routinely died be readily available, and the concepts of community of infection, accident, and acute illness. Death was a and family are rather flexible and open to individuals\u2019 familiar experience to all members of society. Because interpretation. Typically, the experience of death in most people died at home receiving care and comfort Western cultures involves multiple dimensions that go from family members, people of all ages were exposed far beyond the loss of an individual and generates to the realities of death. Consequently, cultures around numerous psychosocial, ethical, legal, and administra- the world developed grieving rituals to help the tive challenges. For that reason, death and dying in deceased person\u2019s family and immediate community contemporary America are frequently subject to regu- process and manage the experience of loss. lations intended to preserve individuals\u2019 autonomy and to provide necessary services and protection to all The end-of-life experiences are very different today. parties. However, in spite of these efforts, many older The advancements of science and technology have led adults and their loved ones do not receive adequate to unprecedented increases in the life expectancy over service and support when faced with death and dying. the last 100 years. Presently, almost 80% of all deaths All too often they are forced to make sense of the ever- occur among people over age 65. With longer life changing rules and regulations completely by them- expectancy, death is becoming increasingly associated selves. This inevitably increases stress and frustration with advanced age, usually the inevitable progression for the dying person and his or her loved ones. The of a chronic and\/or debilitating condition (Box 15-1). unfortunate result is that effective end-of-life care is Typically, individuals with chronic conditions experi- too often delayed to be of maximal benefit. Fortunately, ence repetitive episodes of health crises separated by many organizations, agencies, educators, and health- periods of relative well-being. However, even though care providers are working toward increasing acces- they appear to recover between the episodes, each sibility of the optimal end-of-life care. Organizations health crisis inflicts a certain amount of irreparable 245","246\t UNIT III\u2003 Psychosocial Care of Older Adults treatment modalities that prolong life and want to receive every treatment available. Others prefer a com- Box 15-1\u2003 Causes of Death in Adults Ages 65 fortable death in the presence of loved ones. Many and Older people say that they do not fear death as much as they fear how they will die. \u2022\t Diseases of the heart \u2022\t Malignant neoplasms Many people are uncomfortable talking about \u2022\t Cardiovascular diseases death. Therefore, health care agencies now offer spe- \u2022\t Chronic obstructive pulmonary disease cialized services and referrals to interdisciplinary \u2022\t Pneumonia and influenza teams that provide support to individuals, families, \u2022\t Diabetes mellitus and others making decisions about end-of-life care. \u2022\t Alzheimer disease Family members, nurses, and other caregivers must be \u2022\t Nephritis, nephrotic syndrome, nephrosis able to communicate about end of life to provide good \u2022\t Accidents care for older people nearing the end of their lives. \u2022\t Septicemia These discussions are usually not as traumatic for the older adult as they are for younger people. By the time such as the Institute of Medicine, the American people reach advanced age, most have already experi- Association of Colleges of Nursing, the Robert Wood enced the death of loved ones. Parents, spouses, sib- Johnson Foundation, and the Open Society Institute\u2019s lings, friends, and even children or grandchildren have Project on Death in America have publications and died from many causes and under widely differing websites providing valuable information and resources circumstances. These experiences generally help older to health care professionals and consumers. adults determine what type of care they do or do not want as the reality of death approaches. Most alert ATTITUDES TOWARD DEATH AND older adults are quite candid in expressing their wishes END-OF-LIFE PLANNING if approached in a sensitive but matter-of-fact way. Extended life expectancy and advancement of sciences Ideally, discussions regarding end-of-life care and have changed the average person\u2019s experiences and planning for death should occur before a health crisis perceptions of death. A large number of people in arises. This offers older adults enough time to make Western societies have no direct experience with death decisions when they are calm and can evaluate their and dying until middle or late adulthood. They may situation objectively and according to their personal know someone who has died and may have attended values. When important decisions regarding end-of- a memorial or a funeral service, but few have actually life care are avoided or delayed, family members and been in the presence of a dying person. However, inter- friends of the dying person may have to make deci- est in end-of-life care has been increasing in recent sions in a time of crisis. Unfortunately, they are likely years. This trend is being driven, in large part, by the to be overwhelmed by the approaching death of a Baby Boomer generation who are dealing with end-of- loved one and may not be able to clearly identify and life concerns related to their parents. Soon, these Baby articulate the desires of the dying person. Consequently, Boomers will make up a large part of the senior citizen their decisions may be guided by their own beliefs and population who will need to prepare themselves for values rather than the desires of the dying person. the end of life. Family members may initiate discussion about end- In the past, health professionals often made the of-life preferences with their loved ones after watching decisions about the end-of-life care with minimal input a show, or reading a news article, that deals with from the patient and family. Physicians could unequiv- dying. Similarly, the discussion may be initiated during ocally state, \u201cWe have done everything possible.\u201d This gatherings where the family reminisces about loved is no longer true. Today, health care consumers want ones who have died, or following the death of a friend to actively participate in the decision-making pro- or a family member. Nurses working in outpatient cesses affecting their health and well-being. There is a settings can initiate the discussion while reviewing growing understanding among health professionals patient records. You can ask the older adults if they that health care consumers have a right to guide their have advance directive documents and offer informa- care according to their personal beliefs and prefer- tion about end-of-life care planning. Admission to an ences. The role of health professionals has shifted from acute care setting following a health crisis offers that of a decision maker to that of a service provider another good opportunity to educate older adults whose primary responsibility is to help consumers about end-of-life care. Once the initial crisis has passed, make informed decisions. Consequently, the approach the older adult usually has a high level of conscious- to end-of-life care has shifted from a purely medical ness regarding death and is more likely to recognize focus to a more holistic approach that takes into con- the need to make end-of-life care preferences known. sideration consumers\u2019 personal values, cultural and You can assist by providing the materials needed to spiritual beliefs, and life experiences. For example, initiate advance directives or by offering a referral to some older adults and their families still prefer a social worker or appropriate community resources.","End-of-Life Care\u2003 CHAPTER 15\t 247 ADVANCE DIRECTIVES playing a role in end-of-life care, need to learn to Specific end-of-life decisions can be expressed in recognize their own attitudes, feelings, values, and advance directives and physicians orders for life sus- expectations about death. They need to explore the taining treatment (POLST) (see Chapter 1). These doc- professional literature that discusses legal, ethical, uments specify the type and amount of intervention financial, and health care delivery issues related to desired by someone. Once initiated, they remain in end-of-life care. Everybody involved in the care of a effect until changed. Health care consumers should dying person should collaborate with each other to provide copies of their advance directives to their provide the dying person with holistic care that meets primary care providers, the person holding durable the patient\u2019s physical, psychological, social, and cul- power of attorney, and any other person or health tural needs. In addition, they need to be able to address care agency who might be involved in their care. This the needs of the family, friends, and significant others can prevent last-minute confusion and possible viola- as they face grief, loss, and bereavement at the end of tion of their wishes. If a person does not wish to life. Caregivers need to overcome any feelings of frus- be resuscitated, this has to be accurately recorded in tration or ineffectiveness. They need to learn when and all of their health care records and communicated to how to shift from the aggressive medical interventions anybody potentially involved in resuscitation efforts. designed to cure or extend life to more palliative and The person can choose to wear a bracelet. Caregivers holistic interventions designed to enable the dying must include this information when transferring care, person and his or her loved ones to experience a and if a POLST is in effect, it should be visibly posted \u201cgood\u201d death characterized by comfort, peace, dignity, in the home. and caring. There is no single right plan for the end of life. VALUES CLARIFICATION RELATED TO DEATH The best plan is one that reflects the individual\u2019s AND END-OF-LIFE CARE values and beliefs. Guidance and support from physi- cians, clergy, nurses, social workers, and family can Beliefs, attitudes, and values regarding the experience help a dying person make these significant decisions, of death and end-of-life care vary widely. Individuals\u2019 but each person must ultimately make their own responses are influenced by their age, gender, culture, choices. religious background, and life experiences. Caregivers should reflect on their personal values related to the The decisions about end-of-life care are not set in end of life to identify those values that are likely to stone and can be changed as the situation changes. To influence their decision-making processes and behav- make an informed decision about a specific interven- ior when caring for dying patients. Ethical dilemmas tion or treatment, a patient must have enough informa- relating to end-of-life care are more likely to occur tion including (1) the amount of time a treatment will when the value systems of the patient and of the care- add to life; (2) the quality of life with this treatment; giver differ significantly. Understanding the value (3) the amount of pain, disability, or risk involved with systems of others can help the nurse provide quality the treatment; (4) the amount of time involved in the end-of-life care, even when the nurse does not share treatment; (5) the cost of treatment and whether it is the same values. covered by insurance; (6) the need for and availability of caregivers; and (7) the availability, benefits, and Critical Thinking risks of other treatment options. The information must be provided by the practitioner providing the treat- \u2002 ment, but patients have a right to discuss their treat- ment options with anybody, including their loved Values Clarification Exercise Related to the End of Life ones, who might help them make decisions for their treatment. If they are not satisfied with the information Complete the following statements and reflect on your answers. received from a specific health care practitioner, they What do they tell you about your perceptions and values have the right to request further consultation with regarding end-of-life issues? another practitioner. 1.\t Death is \u2026 CAREGIVER ATTITUDES TOWARD 2.\t Death means \u2026 END-OF-LIFE CARE 3.\t After death \u2026 Even caregivers who routinely care for critically ill or 4.\t Decisions about my end-of-life care should be made \t dying patients may have difficulty accepting death. Many health care professionals have become so focused by \u2026 on preventing illness or curing disease that they are 5.\t Talking about dying makes me feel \u2026 more likely to view death as a personal or professional 6.\t When I am nearing the end of life, I want my family to \u2026 failure rather than the inevitable end to the human 7.\t When I am nearing the end of life, I want my caregivers experience. All caregivers, including nurses, physi- cians, social workers, family members, and others to \u2026 8.\t As death nears, I am afraid of \u2026 9.\t I am in pain as I near the end of life \u2026 10.\t I am dying and I do not want \u2026 11.\t Because I am old, death \u2026 12.\t After I die, I want people to \u2026","248\t UNIT III\u2003 Psychosocial Care of Older Adults outcomes that are most valued and desired by those nearing the end of life and by their families. Themes Critical Thinking throughout all of the studies indicate that given their choice, most people wish to be treated with respect \u2002 and dignity and to die quietly and peacefully with loved ones nearby. Box 15-2 identifies the common Personal Beliefs and Attitudes About Death threads identified by these studies. \u2022\t What are your personal experiences with death? Nurses need to be able to assess the needs of a dying \u2022\t Have you lost a close friend, family member, or patient \t person and plan the care accordingly to facilitate healthy experience of death and dying. Human needs to death? at the end of life follow the universal pattern of human \u2022\t How did you feel when you heard that the person had needs. Figure 15-1 summarizes the needs of dying person using Maslow\u2019s Hierarchy of Needs. died? \u2022\t If you have had more than one experience, did you respond differently to the deaths? Why do you think you responded differently? \u2022\t Have you ever been with a person at the time of death? \u2022\t What thoughts crossed your mind as the person died? \u2022\t Were other people present? \u2022\t What was said or done? \u2022\t What spiritual or cultural rituals were performed at the time of death or burial? Critical Thinking Box 15-2\u2003 Summary of Patients\u2019 Wishes Related to End of Life \u2002 Most dying patients desire to: Ethical Dilemmas \u2022\t Be able to issue advance directives to ensure their This chapter has identified the most commonly identified wishes are respected wishes of individuals nearing the end of life. \u2022\t Be afforded dignity, respect, and privacy \u2022\t What should happen if one or more of these wishes \u2022\t Know when death is coming and what to expect \u2022\t Have access to information and options related \t conflicts with those of the caregivers? \u2022\t What if a spouse values the companionship of the dying to care \u2022\t Retain control of decision making regarding care person and wants all possible life-extending actions to be \u2022\t Have control over symptom and pain relief provided in conflict with the patient\u2019s advance directives? \u2022\t Have access to emotional, cultural, and spiritual \u2022\t What if a physician or family member determines that a patient cannot cope with hearing a terminal diagnosis? support \u2022\t What if the nurse thinks that the amount of pain \u2022\t Retain control regarding who may be present at the medication ordered is excessive? \u2022\t What should be done if death seems imminent during the end of life middle of the night when no family is present? \u2022\t Know possible options (e.g., hospital, home care, and WHAT IS A \u201cGOOD\u201d DEATH? hospice) and have a choice regarding where and how death will occur Many groups in the United States and abroad have \u2022\t Have time to say goodbye to significant others conducted research to identify specific end-of-life \u2022\t Leave life when ready to go without unnecessary or pointless interventions Self-Actualization and Transcendence To share and come to terms with the unavoidable future Self-Esteem and Self-Efficacy To perceive meaning in death To maintain respect in the face of increasing weakness To maintain independence To feel like a normal person, a part of life right to the end To preserve personal identity Belonging and Attachment To talk To be listened to with understanding To be loved and to share love To be with a caring person when dying Safety and Security To be given the opportunity to voice hidden fears To trust those who care for him or her To feel that he or she is being told the truth To be secure Biological and Physiological Integrity To obtain relief from physical symptoms To conserve energy To be free from pain FIGURE 15-1\u2003 Hierarchy of the dying person\u2019s needs, based on Maslow. (From Touhy TA, Jett K: Ebersole and Hess\u2019 toward healthy aging: Human needs and nursing response, ed 8, 2012, St. Louis: Mosby.)","End-of-Life Care\u2003 CHAPTER 15\t 249 WHERE PEOPLE DIE a disease without attempting to provide a cure; it neither hastens nor postpones death. Palliative care Studies indicate that 90% of people wish to die at affirms life while accepting death as its normal conclu- home. In spite of that, a vast majority of deaths occur sion. Interventions are designed to optimize the in institutional settings, with less than one-fourth of patient\u2019s ability to live as active and complete a life as people dying at home. Approximately half of deaths possible until death comes. Competent adults, regard- occur in hospitals, and another one-fourth occur in less of age, who are suffering from life-threatening extended-care facilities. Death in hospital settings is diseases such as cancer or advanced chronic condi- particularly problematic because hospitals are focused tions, such as emphysema or end-stage renal disease, on curative and restorative care and may not be ideally can, and often do, make the decision that they no suited for end-of-life care. The focus of care in extended- longer desire aggressive treatment, such as chemo- care facilities is on care, not cure. They might offer therapy, assisted ventilation, or dialysis. This does not experience that is closer to the experience of dying at mean that these patients forego all medical interven- home, but even these facilities may not be able to fully tion. They will still receive treatments that support the focus on the dying person\u2019s needs. goal of optimizing their ability to live as active and complete a life as possible until death comes. For The concept of hospice care was developed in example, wounds will be treated and a fracture will be response to the challenges of providing end-of-life placed in a cast. Individuals who choose palliative care care. Rather than referring to a specific care setting, typically choose to decline other procedures such as hospice denotes a care philosophy with the focus on cardiopulmonary resuscitation (CPR), artificial venti- humane, dignified, and compassionate care of the lation, and artificial feeding, which may prolong the dying persons and their loved ones (Figure 15-2). dying process. Medical treatment and nursing care Hospice care has been gaining recognition since 1983, focus on actions that enable the dying person to have when Medicare Hospice Benefit began funding this the highest quality of life for whatever time remains. type of care. It can be delivered in the community or in institutional settings. In 2011, an estimated 1.65 COLLABORATIVE ASSESSMENT AND million health care consumers in the U.S. received INTERVENTIONS FOR END-OF-LIFE CARE hospice care (National Hospice and Palliative Care Organization, 2012). However, in spite of the growing Good end-of-life care requires a coordinated effort of number of hospice users, a lot of dying people still do all caregivers. No matter who is designated as the not receive adequate end-of-life care, mainly because primary caregiver, all parties, including the family, of the failure of health professionals to initiate hospice nurses, physicians, social workers, clergy, psycholo- care in a timely fashion. Nurses can facilitate the gists, dietitians, pharmacists, therapists, and volun- process by advocating for their patients and initiating teers must work together effectively for the good of the early referrals to hospice care when appropriate. dying person. Problem solving requires mutual respect and prompt, effective communication among all PALLIATIVE CARE involved parties. Team members also need to recog- nize the physical and emotional toll on the caregivers According to World Health Organization, palliative working with dying persons and their loved ones. care focuses on reducing or relieving the symptoms of Providing emotional support to caregivers can help them maintain the high level of energy and well-being FIGURE 15-2\u2003 Hospice is a philosophical concept of providing needed to meet the various physical and psychosocial palliative or supportive care to dying people. (From Harkreader H, needs of the dying. Hogan MA: Fundamentals of nursing: Care and clinical judgment, ed 3, 2007, St. Louis: Mosby.) COMMUNICATION AT THE END OF LIFE Effective communication is a challenge at the best of times. Unique demands of end-of-life care can make communication even more challenging. Everything takes on increased importance in this once-in-a-lifetime experience. There is no chance to do things over, so it is essential that everything is done right. One of the most important things caregivers can do is to spend more time with the dying person and to encourage family members to do the same. This might be difficult for nurses who typically care for multiple patients and have to manage competing priorities. To adequately prioritize care, nurses must understand the","250\t UNIT III\u2003 Psychosocial Care of Older Adults loved ones receive the necessary information in a importance of therapeutic communication with the timely manner. Discussions regarding end-of-life expe- dying person and his or her loved ones. Studies indi- riences and care should be clear and truthful. The cate that the majority of people do not want to die dying person and loved ones must receive as much alone. In spite of that, research shows that dying people information as possible about what to expect. Avoid in institutional settings spend a great deal of time using complicated technical terms and whenever pos- alone. One study done in a hospital reports that physi- sible, provide explanations using plain language and cian visits average 3 minutes, nursing personnel visits simple statements. Even simple information or expla- average 45 minutes, and family visits average only 13 nations can be confusing at stressful times and may minutes per day. These statistics mean that the dying need to be repeated. Try to prevent or correct any mis- person is alone for 23 of 24 hours. Another study understandings or mistaken perceptions by summa- revealed somewhat better, but still worrisome, results. rizing, clarifying, and restating what the patient said. In this study, dying patients spent 18 hours and 39 Allow time for response and further clarification if minutes alone in their rooms. Nurses and nursing necessary. assistants spent by far the greatest amount of time, 94 minutes of the day, with the dying person, but most of Within culturally acceptable parameters, actively this time was broken into 45 short, task-oriented visits. involve the patient in discussion regarding the plan of It is interesting to note that physicians spent more time care. Nothing is more demeaning or frustrating to a than expected with patients who had \u201cdo not resusci- dying person than having caregivers discuss and plan tate\u201d (DNR) orders and those receiving palliative care the care without his or her input. Nurses can help the for cancer. Patients with dementia received the least patient work through fears and end-of-life decisions time from physicians. Attention from family members by spending time listening in a nonjudgmental manner. varied widely based on age, availability, culture, and However, sensitive communication cannot be hurried real or perceived proximity to death. or scheduled like a procedure. Therefore, nurses need to manage the care in way that would allow them To establish rapport and maintain therapeutic rela- adequate time to engage with the dying person and his tionship with the recipients of care, the nurse needs to or her loved ones. Nurses must ensure that the amount know as much as possible about the dying person and of care delegated to ancillary personnel does not limit his or her loved ones including personal and spiritual the availability of professional nursing support to the beliefs, cultural background, values, and personal ones who need it most. experiences that may influence decision making and the content of the advance directives for health care. Use reflective and open-ended statements such as: Nurses must demonstrate verbally and nonverbally \u201cThere seem to be things that are worrying you,\u201d \u201cIf that they are approachable and are neither detached you want to talk, I\u2019ll listen,\u201d or \u201cIt must be hard. Do nor indifferent. A good way to start is by consistently you want me to sit with you for a while?\u201d as ways to addressing or referring to the dying person by his or encourage a conversation. Start communication from her name. This shows respect and helps the dying where the patient is, then go where they wish to go. person maintain a sense of self-worth and dignity. An Ensure that the communication is focused on the empathetic word and gentle touch can demonstrate patient rather than the caregiver. The dying person caring. Holding a hand, gentle repositioning, provid- and his or her loved ones should be free to discuss the ing good basic hygiene, and maintaining an aestheti- things that concern them the most, not the topics con- cally pleasing environment free from odors, clutter, cerning the caregivers. and unnecessary medical equipment communicate that the dying person is respected and valued. Whenever possible, the dying person should have adequate privacy to communicate freely and should Nurses must demonstrate willingness to listen to be undisturbed by unnecessary noise and commotion. suggestions, requests, or criticism made by the dying Reassurance that the nurse will keep information person or by the family. Near the end of life, emotions confidential may encourage the dying person to com- run high, and people often feel powerless. The family municate feelings or concerns more freely. This may members and friends of the dying person may deal also encourage a dialogue that can help the dying with their feelings of powerlessness by voicing their person begin a life review through which they can frustrations with the quality of care. Nurses must validate life experiences and enhance his or her level listen to these criticisms without becoming defensive, of peace. whether the criticism is justified or not. Prompt response to requests and ongoing communication When death is near, family members or significant explaining the purpose and goals of care communi- others may wish to remain with the dying person. cates that caregivers recognize the importance of the Most facilities encourage this and provide some accom- dying person\u2019s needs. modations for their comfort. The nurse often needs to explain what to expect as death approaches; how to Answer all questions honestly and directly. If the best communicate with the patient; and what, if any- information is not readily available or cannot be dis- thing, loved ones can do to help make the end of life closed, make sure that the dying person and his or her as peaceful as possible.","End-of-Life Care\u2003 CHAPTER 15\t 251 After the person dies, the nurse need not be afraid DECISION-MAKING PROCESS to express emotion at the loss. Often, particularly in extended-care settings, the nurse and other caregivers The dominant Western perspective tends to emphasize have developed a true affection for the person and will the right of the individual to make decisions regarding need to grieve the loss. Family members often report care, regardless of the views of the family or significant that seeing the nursing staff\u2019s grief actually helped others. This is the basis of laws governing advance them cope with the loss, because they knew that other directives. However, many other cultures, including people cared enough about their loved ones. Asian Americans, African Americans, and Mexican Americans, are likely to view life-and-death decisions PSYCHOSOCIAL PERSPECTIVES, ASSESSMENTS, as family issues that must be discussed and decided as AND INTERVENTIONS a group. These groups are significantly less likely to have initiated any form of advance directives (Cultural CULTURAL PERSPECTIVES Considerations box). Cultural beliefs influence the way one thinks, lives, and interacts with other people. Cultural beliefs also Cultural Considerations influence the way one views death and dying. Each person develops a unique set of beliefs and values over \u2002 a lifetime, but as death approaches, those beliefs and values may be challenged. Understanding people and Religious Practices Regarding End of Life their needs would be much easier if there were predict- able patterns, and all people who shared a cultural \u2022\t Buddhism A person\u2019s state of mind at the time of death heritage thought and acted identically. Of course, this is of great importance. A peaceful state may be achieved is not the case. Wide variations of beliefs and behaviors by listening to friends, family, or monks; reading exist within any culture. Therefore, nurses need to scriptures; and chanting mantras. Buddhists view death assess each individual\u2019s unique preferences and view- not as a continuation of the soul but as an awakening. points to develop a culturally sensitive care plan. Funeral rites last 49 days ending in the rebirth of the When nurses and patients come from different cultural individual. Cremation is common. and religious backgrounds, nurses must be careful not to impose their beliefs and should work to under- \u2022\t Christianity Christians believe in a union with Christ, stand the perspectives of others. The four areas that necessary for the full enjoyment of God and the need a particularly careful cultural assessment are: happiness of heaven. If possible, a special anointing (1) communication about death; (2) the decision- (sacrament of the sick) is performed, and the dying making process; (3) amount and type of intervention person is given a chance to confess his or her sins. that will be accepted; and (4) the significance of pain Depending on the branch of Christianity, cremation and and suffering. organ donation may be prohibited. COMMUNICATION ABOUT DEATH The way people communicate about death is to a great \u2022\t Judaism Anything that may hasten death is forbidden. extent culture specific. For example, the Western Death is viewed as a natural process in movement to a cultural perspective is based on the person\u2019s \u201cright more rewarding afterlife. Extensive rituals are used to to know\u201d their diagnosis and prognosis in order to show respect for the dead and to comfort the living. \t make informed decisions. This differs greatly from After death, the body is not left alone until burial. Special Asian and Native American cultural perspectives, washing and wrapping in a simple shroud with religious which may suggest that speaking about death or symbols are typically done by special religious volunteers. other bad things will diminish hope and produce There is no viewing of the remains; a simple casket is bad outcomes. Asking for clarification of beliefs can used, and the body is always buried, never cremated. \t enhance cultural awareness and ensure compliance In general, autopsies are discouraged unless required \t with privacy issues. To accomplish this, use neutral by law. and open statements such as, \u201cSome people like to get information about their health directly; others prefer \u2022\t American Indian (Lakota) Death is a part of life and we speak to another family member instead. Which do after death; people enter a neutral spirit land. The spirit \t you prefer?\u201d Furthermore, ensure the patient under- is believed to reside in the body and should not be stands questions or information provided. Follow disturbed, so burial is preferred over cremation. A \u201cyes\u201d or \u201cno\u201d responses with questions asking the religious celebration of the person\u2019s spirit is held a year patient if they understood. If there is a language barrier, after death. use a pro\u00adfessional translator rather than a friend or a family member who is emotionally involved. \u2022\t Islam Muslims believe that life on earth is a trial to prepare for the next realm of existence. When death is imminent, the patient must face Mecca and confess sins and beg forgiveness in the presence of the family or a practicing Muslim. After death, the body is washed and wrapped in a clean white cloth and positioned facing Mecca. Burial is performed as soon as possible, after a special prayer. Cremation is forbidden; autopsy is prohibited except for legal reasons. \u2022\t Hinduism Hindus believe in the reincarnation and rebirth of the soul leading to a higher state of completeness. Death is viewed as the temporary stopping of physical activity. The fate of one\u2019s soul after death is determined by the person\u2019s previous actions, the state of mind, the","252\t UNIT III\u2003 Psychosocial Care of Older Adults Critical Thinking time and circumstances of the death, the activities of his \u2002 or her children, and the grace of God. After death, the body is given a final bath and cremated, and the ashes Spiritual Needs of the Dying are scattered in various places to allow the body to mingle with earth, air, and water and return to the It has been said that there are no atheists in foxholes. What elements. connection does this statement have to meeting spiritual needs at the end of life? Amount and Type of Intervention That Will Nurses play an important role in helping dying persons Be Accepted meet their spiritual needs. The following are some The dominant Western perspective focuses on helping guidelines to remember when attempting to meet the people cope with death. Other cultures, such as African spiritual needs of the dying person: Americans, American Indians, Asians, Pacific Islanders, 1.\t Determine whether or not any specific religious and Latinos, are more likely to focus on living and prolonging life. Members of these cultural groups beliefs or practices are important to the patient or might be inclined to choose aggressive interventions his or her family members. at the end of life. These cultures also appear to place 2.\t Assess whether or not the patient has a preferred greater responsibility and expectations on the family, spiritual counselor. When no particular individual church, or social network to provide end-of-life care. is identified, ask the patient whether he or she To some extent, this may explain why hospice care is wishes to receive counsel from anyone else. Spiritual becoming more accepted by some cultural groups but counseling is very personal, and the dying person not by others. should have the right to select whomever he or she wishes. Significance of Pain and Suffering 3.\t Offer choices when available. Most hospitals or The Western perspective focuses on achieving freedom extended-care facilities maintain a list of ministers from pain and suffering. Some other cultures, however, who will visit the dying without concern to denomi- are more likely to view pain as a test of faith or a nation or church affiliation. Not all spiritual coun- preparation for the afterlife, and something that is to selors are equally sensitive to the needs of the dying. be endured rather than avoided. If one spiritual counselor does not meet the patient\u2019s needs, make the patient aware that there are others SPIRITUAL CONSIDERATIONS available. Religious and spiritual beliefs play an important 4.\t Determine whether or not the person wishes any part in the lives of many older adults and may grow spiritual counselor to be notified. Respect the even more important as they approach the end of life. wishes of people who do not wish spiritual counsel. Older people facing the reality of death and dying Spiritual counseling can be very beneficial when often lean on their spiritual beliefs in an attempt to desired. When it is not desired, intervention can make sense of their lives and deal with uncertainties cause more problems than it solves. of death. This may lead to increased spiritual or reli- 5.\t Demonstrate respect for the patient\u2019s religious gious interest and concern, even among individuals and spiritual views. Provide the dying person time who did not express any particular interest in religion for private thought, prayer, or meditation when for most of their lives. desired. Incorporate important activities and items into the care plan. The religious rituals related to There are far too many variations in spiritual beliefs dying can differ widely among cultures, and the and practices to thoroughly address them in this text- nurse should help the family whenever possible to book. Growing recognition of the importance of spiri- facilitate their practices even if this involves moving tual support to the dying persons and their loved ones furniture to face a specific sacred direction, opening has enticed many health care agencies to develop spe- windows, or providing space for a large group of cialized services that provide spiritual care. They are family members. often referred to as pastoral care and may employ 6.\t Do not impose your own beliefs on the patient. clergy, nurses, and other pro\u00adfessionals trained to The nurse should keep the focus of spiritual discus- provide support to patients in need of spiritual support. sions on the patient and his or her beliefs, not on To meet the spiritual needs of diverse populations, the nurse\u2019s beliefs. spiritual care services may use a variety of religious 7.\t Be present, be available, and listen. The nurse counselors including priests, pastors, rabbis, imams, cannot and should not attempt to solve the patient\u2019s mullahs, shamans, and other ministers. The counselors problems, but empathy demonstrates acceptance can be a valuable resource to nurses and other care\u00ad and caring. This allows the patient to feel less alone givers who are trying to tailor care to specific spiritual and often decreases spiritual distress. beliefs and practices. 8.\t Keep the patient\u2019s relevant religious symbols readily available and treat them with respect.","End-of-Life Care\u2003 CHAPTER 15\t 253 9.\t Avoid moving beyond role and level of expertise PAIN unless you have specific ministerial or pastoral Pain is often the most significant concern of the dying training in death and dying. person and his or her loved ones. This is particularly true when the dying person suffers from a highly DEPRESSION, ANXIETY, AND FEAR painful disease, such as cancer. Pain at the end of life An older man once said, \u201cI think that waiting to die is can interfere with the dying person\u2019s ability to main- worse than death itself.\u201d It is one thing to know that tain control, to cope, and to complete end-of-life tasks. you will die eventually; it is another to realize that you It increases the likelihood of fatigue, depression, and have lived most of your life and that death is likely to loss of appetite. Most importantly, pain interferes with be a reality soon. At that point in life, individuals must the ability of the dying person to make thoughtful decide whether they will give up and let fear, anxiety, decisions and to communicate effectively with loved or depression overwhelm them, or whether they will ones at a critical time. do something to remain in control of whatever time they have remaining. Pain at the end of life is a form of suffering. Therefore, treating pain is one of the most important priorities of Nurses can help dying people cope with emotional the care of a dying person. The goal of pain manage- distress by listening to their concerns and helping ment is to reduce pain to an acceptable level as deter- them find constructive ways of dealing with these con- mined by the dying person, while maintaining the cerns. Encourage the dying person and his or her loved level of alertness that allows them to remain aware of ones to participate in creative and pleasurable activi- daily activities and to interact with family and loved ties. Art, poetry, and other writings can provide a ones. Although they may not experience absolute pain means for many dying patients to communicate their relief, the dying person should always be made feelings and leave a tangible message for their family comfortable. and loved ones. Physical activity can help reduce both physical and emotional tension. Relaxation classes Perform a thorough pain assessment as early as pos- or support groups designed to help people dealing sible and as often as needed. The general rule that with terminal conditions may help decrease social \u201cpain is what the patient says it is\u201d also applies to the isolation. end-of-life care. However, older adults with multiple chronic conditions tend to underreport pain and often Everyone has good days and bad days. When there do not ask for pain relief until it reaches relatively high are more bad days and these bad days seem to be levels. Caregivers should review pain rating with the getting worse, professional help may be necessary. A patients and encourage them to report it as soon as psychological evaluation may be needed to determine they experience it. Besides intensity, pain assessment the nature and severity of the problem. Counseling should include evaluation of the frequency, location, and use of antidepressant or antianxiety medications quality, and duration of the pain, as well as identifi\u00ad can help. cation of the precipitating and relieving factors. Document all pain assessments carefully. Pain assess- Anger is not uncommon, particularly soon after a ment flow sheets can be used to communicate changes terminal diagnosis is made. The nurse should accept in pain status. Teach the dying person and his or her this; allow patients the opportunity to verbalize their loved ones how to keep a pain log that supplements anger, and then help them find ways to move forward nursing assessments. This log should be simple enough and to cope with the future. More general approaches for a lay person to understand and should include all are discussed in Chapters 11 and 13. of the factors a nurse would assess. Self-reported logs are helpful, because the patient and his or her signifi- PHYSIOLOGIC CHANGES, ASSESSMENTS, cant others are more focused and attuned to subtle AND INTERVENTIONS changes in the individual. Pain logs often reveal impor- tant information that would otherwise be missed No one can say exactly when a person will die, but (Figure 15-3). a pattern of physiologic changes can help predict when the end is near. Typical physiologic changes Meticulous pain assessment is particularly impor- observed as death nears include fatigue, dyspnea, tant when providing care to dying persons who are not gastrointestinal changes (dry mouth, anorexia, nausea able to verbalize their distress. Changes in level of and vomiting, constipation), anxiety, and delirium. consciousness do not affect one\u2019s ability to feel pain; Pain is not always present as death nears, but when it just the ability to express pain. Use alternative assess- is present, pain relief is a priority. As death approaches, ments with patients who cannot communicate ver- the ultimate goal of care is to alleviate suffering and bally. Begin the assessment by reviewing whether the provide the dying person with the highest level of patient has an existing condition or has recently expe- comfort possible. Effective end-of-life care requires rienced some trauma that may cause pain. Perform commitment, creativity, and caring. This may involve head-to-toe assessment to determine whether there are use of a variety of traditional, complementary, and any objective data that might indicate the source of technologic approaches.","254\t UNIT III\u2003 Psychosocial Care of Older Adults Date Time Severity of Pain Activity at Time of Pain Medication Given Comfort Measures Severity of Pain in 1 Hour 6\/2\/16 0800 level 6 \u201cmostly walking in hallway morphine sulfate encouraged to rest level 2 \u201cnot entirely gone, in my back\u201d 30 mg back massage given but I can tolerate this\u201d FIGURE 15-3\u2003 Sample pain management log. pain, such as swelling, inflammation, or bruising. swallowing oral medication, consider switching During the assessment, carefully observe the patient to liquid, transdermal, or rectal formulations. for any responses, such as restlessness, moaning, Parenteral administration of medication may not guarding, grimacing or striking out, when body parts be the first choice for an older adult unless he or are touched or moved. The presence of any of these she has an existing IV or central line, peripherally responses between assessments, especially during inserted central catheter (PICC), or implanted port. routine activities, such as repositioning, can also indi- 5.\t Pay attention to timing of pain medication. Pain cate the likelihood of pain. Family members, friends, medications are most effective when taken before or staff members may be aware of behaviors the patient the pain becomes severe. Long-acting or sustained- exhibits when in pain. This information should be release opioids are commonly ordered because they indicated on the plan of care, so that all care providers are effective at maintaining pain control although can respond appropriately. eliminating the need to disturb the patient fre- quently to administer pain medication. Even with Good pain management requires a thorough under- long-acting pain control, breakthrough pain may standing of the patient\u2019s needs and wishes. This occur. Treat it promptly with a rapid-acting analge- involves in-depth evaluation of the dying person\u2019s sic. Administer as-needed (prn) medications as physical needs, coping abilities, and support network, soon as possible when requested. as well as the evaluation of religious and sociocultural 6.\t Never abruptly stop pain medications when factors that may affect his or her pain experience. they have been taken for an extended period. Recommendations for end-of-life pain management Withdrawal symptoms including headache, shaki- are constantly being updated as new evidence becomes ness, or diaphoresis can occur if medications are available. Nurses and other health professionals must stopped suddenly. be aware of the new developments and continually 7.\t Use nonpharmacologic approaches to complement update their pain management practices. The follow- pharmacologic interventions when managing pain. ing is a list of evidence-based principles for the pain Discuss possible options and implement those that management at the end of life: are most acceptable to the patient. Activities that 1.\t Do not give up trying to find an effective pain- may help provide relief include (1) hot or cold applications such as warm baths, showers, cool control regimen. It may take several attempts to wash cloths, or ice packs; (2) comfort devices such find the best combination of medication and non- as cushions, pillows, and pads; (3) massage, foot pharmacologic approaches to reach a pain level that rubs, or reflexology; (4) relaxation breathing or is tolerable for the patient. other relaxation exercises; (5) imagery or visualiza- 2.\t The likelihood of drug-drug and drug-disease tion; (6) distractions such as socialization, listening interactions or adverse effects increases with to music, and watching television or movies; (7) the addition of new medication or higher doses. biofeedback; (8) transcutaneous electrical nerve Careful assessment is needed each time a change in stimulation; (9) hypnosis; and (10) anything else medication is made. that helps reduce stress. 3.\t Frequently evaluate the effectiveness of pain man- 8.\t Consider referral to a pain specialist. If the dying agement. Doses and frequencies of medications patient does not experience adequate pain control, might need to be changed or adjusted based on the consult a pain specialist, such as clinical nurse spe- response. Thorough assessment reveals when the cialist or a palliative care practitioner. medication is no longer providing adequate pain Sedation using neuroleptics, benzodiazepines, barbi- relief. turates, or high doses of opioids may be ordered when 4.\t Consider using a variety of routes of administra- the pain is severe and not relieved by using standard tion. Oral medication is the most common and narcotic medications. Use these with caution because accepted route for administration, but it may cause they can induce dangerous side effects. Generally, problems for older adults who have difficulty sedation is not the ideal solution, but it may be used swallowing pills. Never crush solid medications when it is the only way to alleviate extreme suffering designed for sustained release, because this results in rapid absorption. When the person has difficulty","End-of-Life Care\u2003 CHAPTER 15\t 255 and distress. It should be used after the patient, family, difficulties. However, dyspnea is a subjective sensation or health care team is able to determine that it is in the of difficulty breathing and may not be easy to observe. person\u2019s best interest. The health care team must be Respiratory rate and oxygen saturation cannot predict aware of the need for ongoing communication with the the severity of dyspnea. A dying person may report family members, who may experience fear or a change feeling breathless even though oxygenation levels are of heart regarding the treatment plan. Once sedation satisfactory and typical signs of breathing difficulties begins, it may be reduced or terminated if the family are absent. Treatment should focus on symptom man- or healthcare representative requests. This, however, agement and elimination of the underlying causes may result in the recurrence of physical and emotional when possible. distress for the dying patient. Therefore, many health care agencies have policies guiding the use of sedation, Mild respiratory difficulty usually can be relieved including the types and amounts of medication that by changing positioning, elevating the upper body, can be used. Careful documentation of all interven- opening windows or using a fan to increase ventila- tions is essential. tion, or administering oxygen by nasal cannula. Both physical and emotional stress can cause muscle Some practitioners have expressed ethical concerns tension, which exacerbates respiratory problems. about the use of sedation in end-of-life care as a form Encourage the dying person and their visitors to mini- of passive euthanasia. However, a majority of clini- mize stressful experiences and to alternate episodes of cians and legal experts do not support this view, activity with rest periods. Excessive talking and visit- because the purpose of sedation in end-of-life care is ing should be minimized if they cause problems. to reduce suffering, not to end life. This view has been Visitors need to know that it is sometimes better to supported by legal practice and the positions state- visit for shorter periods of time or to leave the room ments of the professional bodies representing nurses, and allow the patient to have some quiet time if breath- physicians, and other health professionals. ing difficulties occur. Resting in a reclining chair or FATIGUE AND SLEEPINESS elevating the head of the bed usually aids effective Fatigue accompanies many conditions and is not breathing. Listening to music and using relaxation specifically a sign of impending death. Fatigue can exercises may further help reduce tension and improve interfere with the dying person\u2019s ability to carry out breathing effort. necessary end-of-life tasks, including communicating with loved ones. Sometimes, stimulants such as caf- Severe breathing problems, such as those seen with feine or prescription drugs, may help a person over- chronic heart or lung disease, usually do not respond come fatigue and lethargy, but these should be used well to these simple measures and need treatment that cautiously. Teach the patient to pace their physical is more aggressive. Acute distress, fear, and panic fre- activity and schedule frequent rest periods to reduce quently accompany severe shortness of breath. When fatigue. Because of metabolic changes, the patient may the dying person does not want aggressive medical begin to sleep more and may be difficult to arouse as treatment, the most common method used to manage the end of life nears. shortness of breath is administration of morphine. The CARDIOVASCULAR CHANGES patient, family, and team of caregivers need to be Diminished peripheral circulation already common in aware of and be comfortable with the fact that mor- older adults is likely to worsen as death nears, result- phine, when given in a dosage that is adequate to ing in dry, pale, or cyanotic extremities. Peripheral relieve the respiratory distress (via pulmonary vasodi- pulses are often weak and difficult to palpate. Blood lation), can cause drowsiness, sleep, and even loss of pressure typically is decreased by 20 or more points consciousness. from the normal range and may be difficult to auscul- GASTROINTESTINAL CHANGES tate. Body temperature may elevate significantly as Loss of appetite (anorexia) and muscle wasting death nears. (cachexia) often accompany advanced terminal condi- tions, particularly some forms of cancer. Many factors Adjust room temperature and ventilation to promote contribute to poor appetite and weight loss in the ter- comfort while avoiding chilling drafts. Use comfort minal patient, including medications, sores in the measures such as bed socks, shoulder wraps, and mouth, changes in taste, nausea and vomiting, meta- warmed blankets (never electric because of risk for bolic changes, absorption problems, and emotional burns). Heavy or restrictive covers should not be used depression. Treatment of anorexia and cachexia is dif- because they may increase discomfort. ficult because many of the underlying physiologic RESPIRATORY CHANGES actions are poorly understood. Dyspnea is common as death nears. A dying person may experience shortness of breath, Cheyne-Stokes The anorexic person should be encouraged but respirations, and other observable signs of respiratory not forced to eat. Force-feeding will make the person more uncomfortable and can result in choking. Care should focus on whatever pleasures attached to food that remain. Inquire about food preferences and","256\t UNIT III\u2003 Psychosocial Care of Older Adults age, medications, and decreased fluid intake. This accommodate special requests when possible. The end problem, although not unique to the dying person, of life is not a time for special or restricted diets. causes increased distress and discomfort that can Encourage the person to eat anything that appeals to and should be avoided as the end of life nears. A him or her. Present food in an appealing manner and humidifier or pans of water (for evaporation) increases in a quantity that is not overwhelming. Whenever pos- moisture in the air. Moist air helps prevent drying sible, serve meals in an odor-free environment. Food of the skin and mucous membranes and may ease is intimately attached to good times and social events. breathing. Common measures used to treat dry mouth Watching a loved one waste away is very disturbing include frequent swabbing with mouth sponges, to family members. With best intentions, they may try spraying the mouth with water mist from an atomizer, to force a dying person to eat. Enlisting the family to and brushing the teeth. Avoid alcohol-based swabs bring small amounts of special foods from home may because they tend to further dry mucous membranes. bring back pleasant memories of better times. Sharing Commercial lip balms or liquid vitamin E may be a meal with family members can be a positive experi- helpful in easing the discomfort of dry lips. Petroleum- ence, even when the person consumes very little. based products, such as Vaseline, may cause respira- tory problems if they are inhaled and should not be The issue of artificial feeding typically arises when used on the mouth. a dying person is unable or unwilling to eat. Artificial nutrition and hydration can be delivered through a Nausea and vomiting are not signs of impending feeding tube or via parenteral route. Artificial feeding death; rather they are distressing symptoms of under- bypasses normal mechanisms and response to thirst lying problems such as adverse medication reactions, and hunger, thus increasing risk of aspiration, nausea, constipation, intestinal obstruction, or other physio- vomiting, infection, and other complications. It also logic changes. Vomiting increases the risk for aspira- bypasses the usual processes associated with food tion, so it is best to position the patient in a side-lying ingestion, such as tasting, chewing, and swallowing or sitting (Fowler) position rather than supine. food. Although it might provide energy, artificial Temporary relief from nausea and vomiting may be feeding is generally uncomfortable and does not satisfy obtained by rectal or parenteral administration of anti- other needs normally met by eating. Therefore, the emetic medications, but the underlying cause must be need for artificial food and hydration has to be evalu- identified and corrected before the symptoms will go ated with care because it might be more of a burden to away. If a medication reaction is suspected, contact the a dying person than a benefit. Many health care con- prescribing practitioner. sumers address this issue in their advance directives by specifying what forms of feeding, if any, they would Constipation is a common and distressing problem permit. for the terminal patient. Common causes of constipa- tion near the end of life include disease factors such Inability to take food and fluids by mouth is a as tumor compression, calcium imbalance, adhesions, part of the normal progression to death. The choice to dehydration, inadequate fiber intake, pain, immobility, stop eating is something different. People may stop and medications (e.g., opioids, antidepressants, and eating as a method of hastening death. This may be a antacids). Prevent constipation whenever possible. A conscious decision or it may be a response to uncon- high-fiber diet, bulk-forming supplements such as trolled pain or severe depression. Be alert to these pos- psyllium, and adequate fluid intake might prevent sibilities and find out the reasons. Adequate pain problems while the patient is able and willing to eat. control and actions to reduce the depression may cause Stool softeners, laxatives, suppositories, or enemas changes in the person\u2019s behavior. The idea of self- are indicated when dietary intake is not adequate, starvation is usually traumatic to family members and but they may cause electrolyte imbalance. As the end caregivers. of life approaches and muscle tone in the rectum decreases, manual disimpaction might be required People can live for days without food. Prolonged to decrease rectal pressure and pain. Disimpaction fasting leads to ketosis, which depresses hunger and should be done gently and carefully using adequate may even result in mood elevation or euphoria. There lubrication (K-Y Lubricating Jelly or petroleum is no evidence that self-chosen food refusal causes jelly). Use extreme caution before performing rectal suffering. Dehydration is more likely to cause death examination or digital removal when the person has than is starvation. People can survive for only a few thrombocytopenia. days without fluid. On the other hand, dehydration appears to have some benefits near the end of life. It Diarrhea is a less common problem at the end of is theorized that dehydration leads to the release of life, but it may have a profound effect on the quality endorphins (i.e., natural chemicals that reduce pain). of life. Repeated episodes of diarrhea contribute to Dehydration also reduces fluid congestion in the electrolyte imbalance, dehydration, skin breakdown, lungs, making breathing easier, and reduces respira- fatigue, and depression. Diarrhea can be caused by tory secretions, reducing the need for suctioning. numerous factors, including disease processes, psy- chological factors, medications, herbal remedies, Dry mouth (xerostomia) and ulcerations of the mouth can be caused by many things such as advanced","End-of-Life Care\u2003 CHAPTER 15\t 257 hypersensitivity to light and sound, fleeting illusions, bacterial or parasitic infections, and antibiotic therapy. visual hallucinations, delusions, mood swings, atten- Treatment may include increased clear fluid intake tion deficits, and memory disturbances. to replace electrolytes, antibiotics to treat infectious diseases, steroids to decrease bowel inflammation, Many forms of delirium are treatable if they are medications, or bulk-forming agents to slow intestinal recognized and reported promptly. Causes of delirium peristalsis. To avoid an obstruction, use bulk-forming include: hypotension; oxygen deprivation resulting agents only when the person has adequate fluid intake from apnea or hypoventilation; fever; neurologic of approximately 2000\u202fmL\/day. changes; metabolic abnormalities, such as hyperglyce- mia and uremia; dehydration; and other physiologic URINARY CHANGES or emotional disturbances. Medications such as antibi- Oliguria is commonly observed because of decreases otics and opioid analgesics can also contribute to delir- in fluid intake, blood pressure, and kidney perfusion. ium. Vital signs, oxygen saturation, and laboratory Urinary incontinence is also common. Absorbent values may provide valuable information about under- pads or an indwelling catheter can be used to reduce lying problems. the need for bed changes that may disturb the dying person. Delirium is disturbing to the dying person, his or her family and loved ones, and the caregivers. Some INTEGUMENTARY CHANGES decrease in symptoms may occur with simple inter- Skin breakdown is a problem with malnourished ventions such as calm, reassuring support. Treatment patients near the end of life. Interventions designed to is aimed at restoring the baseline cognitive level as is prevent skin tears or pressure sores include proper possible. Individualize treatment to meet the needs of skin cleansing, careful handling of the skin, frequent each person. Correction of underlying physiologic or turning and positioning, and measures to reduce pres- metabolic problems may bring some relief, as may dis- sure. Chapter 17 provides further information on the continuation of some medications. prevention of pressure sores. DEATH Soft, nonconstricting, nonirritating (free from harsh detergents and other chemicals) clothing promotes The experience of death in an institutional setting is comfort and minimizes risk for skin dryness and very different from the experience of death at home. rashes. Comfort should take precedence over style. Family members, significant others, and friends often Older, loose, cotton clothing is often best, particularly wish to be present at the time of death. However, some when the person is diaphoretic. A major advantage of families might be able to spend only a limited amount cotton is that it breathes, allowing perspiration to of time with their dying loved one and wish to be escape, which helps keep the skin dry. called only when there is a significant change in the person\u2019s status. Others would rather be notified only SENSORY CHANGES after death has occurred. Family decisions are influ- Vision diminishes, and the visual field narrows as enced by a multitude of factors including coping death nears. To compensate for this change in vision, ability, access to resources, work situation, health of caregivers and loved ones must come close to the family members, and personal factors such as the age, dying person to be seen. Indirect lighting with minimal health, and relation to the dying person. Everybody shadows is most restful and least disturbing. Hearing copes with the death of a loved one in a unique way remains acute until death, even if the dying person and needs to be supported in a professional and non- does not respond. All caregivers and visitors must judgmental manner. The following strategies can help remember this when they speak in the presence of a caregivers provide the support to the family through dying person. Calm, supportive, loving messages this experience: should be delivered to the person even when he or she 1.\t Discuss the family\u2019s wishes early, so that appropri- does not respond. Avoid negative or disturbing con- versations because they can cause the dying person to ate notification of family, clergy, and others can become distressed and more agitated. take place. 2.\t Record and communicate instructions on who to CHANGES IN COGNITION call, how they can be reached, and whether there Delirium, an acute change in mental status, affects as are any limitations regarding time of day. many as 80% to 85% of older adults in the last days of 3.\t Offer family members the opportunity to partici- life. As death nears, periods of delirium may be com- pate in the care of the dying person. Families often bined with periods of coherent thought. Common want to be helpful. Educate them and provide them symptoms include decreased ability to think and with opportunities to participate in the care. process information, perceptual changes, disorienta- 4.\t Allow family members to express their emotions tion, loss of consciousness, insomnia with daytime and provide them with support. Some family sleepiness, nightmares, agitation, irritability, anxiety, members may be hesitant and may need permission to express their emotions, although others might be","258\t UNIT III\u2003 Psychosocial Care of Older Adults depending on agency policies. When death occurs in a shared room, make arrangements to provide privacy very demonstrative when it comes to grief. Ensure without unduly disturbing the surviving resident. they feel comfortable and supported. Some facilities provide a special room for these 5.\t Provide frequent updates on the condition of the situations. dying person, and be available to answer questions. Families often need assurance that the person is Perform postmortem care in accordance with cul- comfortable. Provide comfort measures and be sen- tural and spiritual preferences. Typically, this includes sitive to the needs of the family members. removing any soiling and applying a clean sheet or RECOGNIZING IMMINENT DEATH shroud according to agency policies. In most cases, the Some physiological changes may indicate approaching head is elevated slightly to prevent discoloration. death, but there is no way to predict the exact moment Gently close the eyes, insert dentures, and position a or manner of death. small towel to close the mouth. This gives the face a Some indicators of imminent death may include, more natural appearance if a funeral visitation is but are not limited to, the following: desired. Most health care facilities have policies and 1.\t Increased sleepiness guidelines to guide the personnel through administra- 2.\t Decreased responsiveness tive and legal procedures related to death. The nurse 3.\t Confusion in a person who has been oriented in attendance needs to note and document the time of 4.\t Hallucinations about people (sometimes deceased death if witnessed. When death is not witnessed, time family members) of death needs to be approximated. Notify the physi- 5.\t Increased withdrawal from visitors or other social cian and funeral director specified by the family interaction according to agency policies. Identify, list, and bag per- 6.\t Loss of interest in food and fluids sonal belongings for return to the family. 7.\t Loss of control of bowel and bladder in a person who has been continent Coordinated Care 8.\t Altered breathing patterns such as shallow breath- ing, Cheyne-Stokes respirations, and rattling or gur- \u2002 gling respirations 9.\t Involuntary muscle movements and diminished Delegation and Supervision of End-of-Life Care reflexes Death may be sudden and quick, or it may be slow and END-OF-LIFE CARE gradual. Some individuals experience acute physio- \u2022\t Nursing assistants who work with dying patients may logic changes that results in relatively quick death. They are alert and talking one minute and gone the have many concerns related to end-of-life care. next. In other individuals, bodily function shuts down \u2022\t Agency policies and licensed nursing personnel should system by system, heart rate slows, respiration fades, and the individual slowly slips away. Signs of death provide guidance so that nursing assistants know what is include absence of heartbeat and spontaneous respira- expected of them. tions; open eyes without blink; nonreactive pupils; \u2022\t Some concerns that need to be addressed include (1) flaccid jaw with slightly open mouth; and lack of what information regarding changes in status they should response to touch, speech, or painful stimuli. Legal report; (2) whether they should start CPR in light of the pronouncement of death is made by the physician. patient\u2019s code status; (3) how they should respond to If family members are present when the patient questions from the family; and (4) how to respond to expires, they should be allowed to sit at the bedside abusive or difficult family members. and say farewells or grieve as long as necessary. \u2022\t Supervising nurses can work to recognize and meet the Discretely remove oxygen, IV lines, and other visible needs of their staff. medical devices, and turn off monitors and other \u2022\t Many nursing assistants, particularly those in long-term noise-creating equipment. Accommodate and show care settings, become attached to older patients and respect for cultural practices regarding grieving and grieve when they die. The nursing assistants may feel preparation of the body whenever possible. Give the unprepared and have difficulty dealing with a death. \t family adequate amount of time and provide them They may need reassurance if they feel guilty of doing with nursing care until they are ready to leave. This is something wrong when a patient dies after an activity not the time to avoid the family. A word of support, a such as bathing or ambulation. They may need guidance, simple hug, or other demonstration of sympathy by and they may be concerned that they may have said the nurse is long remembered by family members. something that upset the dying patient or the family. They Allow the deceased person to remain in the room if may need support when they are criticized and demeaned other friends or family members who were not present by family members who rarely visited the patient during at the time of death wish to assemble. The deceased his or her life and who appeared only when death was person may remain in the room until the funeral direc- near. They may need empathy when they are expected, tor arrives or may be transported to the morgue, as another task, to prepare the body of the deceased when they need an opportunity to grieve the loss. FUNERAL ARRANGEMENTS Many religious and cultural implications are related to the handling and burial of the deceased person. Older people have usually given some thought to their final","End-of-Life Care\u2003 CHAPTER 15\t 259 resting place, and many have made specific plans, numbness are unavoidable. For a few weeks after issued specific directions regarding their wishes, and death, people describe their behavior as \u201cbeing in a even paid for their funeral. Activities following death fog\u201d or \u201cgoing through the motions.\u201d After this initial are easier when advanced planning has taken place. time, the reality of the loss strikes and survivors are Ideally, the family should not be forced to make diffi- likely to experience signs of depression, such as loss of cult choices at a time of high emotion. It is common appetite, inability to sleep, avoidance of social interac- for grieving families to commit to expensive caskets or tion, and uncontrolled bouts of crying. They may also services that place an unnecessary financial burden on be angry with the person who died and voice state- the family. Some patients do not want burial, but prefer ments such as, \u201cHow could he do this to me?\u201d Talking cremation. to the deceased loved one is not abnormal and may be useful for some individuals. Funeral services also are highly influenced by culture and religion. In most cultures, some type of In normal grieving, the frequency and severity of service takes place after death to memorialize the life these signs of grieving gradually decrease over time, of the deceased and to allow the family to begin to but the loss of a loved one never goes away completely. work through some of their grief. Nurses and other Life goes on, but it is not the same as before. Life does caregivers sometimes desire to attend services for not seem to be the same without the loved one. Most long-term patients. This is appropriate when possible people who lose a loved one require at least a year and is often greatly appreciated by the family. to work through the most severe phase of emotional distress. Grief counselors often evaluate a person\u2019s BEREAVEMENT responses at the first anniversary of the death as an indicator of his or her adjustment. It is common for Death typically elicits a complex psychosocial and grieving to last longer than a year, but severe adjust- physical response in everyone associated with the ment problems at this point indicate the need for more deceased person, be it as a significant other, a family aggressive help. member, a friend, or a caregiver. Entire books have been written on coping with death and dying. This Nurses can help grieving individuals in several chapter provides only general guidelines (Box 15-3). ways. They can encourage the grieving person to take Nurses who deal with dying patients and their loved time to cry and to express his or her feelings. They can ones should plan to obtain some additional resources listen to the grieving person talk about the loved one. from the library or bookstore. Review and reminiscence about good times may bring tears, but it gives the person opportunities to gain There is no single \u201cgood\u201d or \u201cright\u201d way to feel after strength from having known the loved one. When a person dies. Survivors often experience ambivalent appropriate, recommend bereavement support groups, feelings regarding the death. On one hand, they feel a which use sharing of mutual experiences to help indi- sense of relief that the struggle is over and that the viduals coping with loss and grief. Collaborate with loved one is at rest. On the other hand, they seriously other health team members to provide support and grieve and miss the loved one\u2019s presence. Even when initiate a referral to a grief counselor for individuals death is anticipated, the initial feelings of shock and who are experiencing severe or protracted grief. Box 15-3\u2003 K\u00fcbler-Ross Stages of Grief resolutions to change their behavior or lifestyle based on these reflections. Remorse and guilt that they did not do The following stages were identified by Dr. Elizabeth K\u00fcbler- enough are common and can slow the grief process. Ross in her groundbreaking book, which was the first to address grief related to death and dying. Although listed in DEPRESSION a sequence, these stages do not necessarily follow in this Feelings of emptiness, loneliness, and isolation are common specific order. A person may move in and out of the stages after the loss of a loved one. Frequent crying spells, inability unpredictably and erratically. to sleep, inability to concentrate or make decisions, and loss of appetite are typical. Some survivors describe their lives\t DENIAL as colorless and meaningless. Many people try to hide their Numbness protects the survivor from the intensity of the loss. feelings and suffer needlessly. Support from family, friends, This typically decreases as the individual acknowledges the nurses, physicians, and bereavement groups can help the reality and permanence of the loss. survivor work through feelings of depression. Antidepressant medications are sometimes used on a short-term basis. ANGER Feelings of anger are often directed at the deceased or at a ACCEPTANCE deity because the survivor feels abandoned. Anger is one There is no set time limit for grief over the loss of a loved method for dealing with the feelings of helplessness and one. Acceptance and healing occur slowly as the person powerlessness. Anger tends to decrease over time. works through his or her feelings and reestablishes a meaning and pattern to life. BARGAINING Survivors try to identify whether they could have done\t something different to prevent the loss. Some may make Data from K\u00fcbler-Ross E: On death and dying, 1969, London: Routledge.","260\t UNIT III\u2003 Psychosocial Care of Older Adults 2.\t A calorie-restricted, low-sodium diet was prescribed for a terminally ill patient who has diabetes, is in renal Get Ready for the NCLEX\u00ae Examination! failure, and has a do-not-resuscitate order. As death nears, the patient has very little appetite and picks at Key Points the food. What should appropriate nursing interventions include? (Select all that apply.) \u2022\t Eighty percent of the deaths in the United States occur 1.\t Continue diet as ordered. in the older-than-65 population. 2.\t Encourage family to bring in small amounts of food from home. \u2022\t Despite increased attention by professional 3.\t Serve food in a place free from odors. organizations and groups, death and end-of-life care do 4.\t Encourage the person to eat anything that appeals not receive adequate attention in nursing education or to him or her. society as a whole. 5.\t Require person to eat at least one bite of each food group. \u2022\t Many older adults do not desire aggressive medical 6.\t Provide good oral hygiene. intervention at the end of life, so caregivers need to be prepared to provide palliative and holistic interventions. 3.\t Dyspnea, shortness of breath, and irregular breathing patterns are common as death nears. Which simple \u2022\t Older patients and their families need to be included in measures taken by the nurse would help alleviate mild planning for end-of-life care. respiratory difficulty? (Select all that apply.) 1.\t Administering oxygen by nasal cannula \u2022\t Most older adults state that they wish to die at home, 2.\t Administering prn atropine sulfate but most deaths occur in institutional settings. 3.\t Instituting measures to reduce anxiety or tension 4.\t Elevating the head of the bed \u2022\t Culture and ethnicity play a role in beliefs and 5.\t Administering prn morphine per physician\u2019s order expectations related to the end of life. 6.\t Reminding visitors not to tire the patient \u2022\t Most individuals fear that they will die in pain. Nurses 4.\t List the five stages of death and dying identified by must work to allay this fear and provide adequate pain K\u00fcbler-Ross. control for dying patients. 1.\t ____________________________________________ 2.\t ____________________________________________ \u2022\t Although it is not possible to predict exactly when a 3.\t ____________________________________________ person will die, several physiologic changes occur as 4.\t ____________________________________________ death approaches. 5.\t ____________________________________________ \u2022\t The nurse needs to provide ongoing care to minimize 5.\t Which is true about the presence of pain at the time of preventable problems and discomforts. death? 1.\t One of the greatest fears of the dying person \u2022\t Family members need to be apprised of the 2.\t Usually of short duration and readily treated with significance of physiologic and behavioral changes that analgesics occur as death nears. 3.\t Normal, expected, and unavoidable 4.\t Likely to require high doses of narcotic analgesics \u2022\t Nurses can play an important role in helping survivors deal with grief after the death of a loved one. 6.\t The nurse is interviewing a patient whose husband died 18 months ago. Which statement indicates that the Additional Learning Resources patient is adjusting to the loss? 1.\t \u201cI miss my husband every day. Focusing on our \u2002 Go to your Evolve website at http:\/\/evolve.elsevier children and going back to work helps me focus on .com\/Williams\/geriatric for the additional online resources. future.\u201d 2.\t \u201cSeeing our children grow without a father is too Review Questions for the NCLEX\u00ae Examination hard for me. I often wonder if I can go on.\u201d 3.\t \u201cI sent my children to my parents. I don\u2019t think I can 1.\t Which of the following statements is incorrect? be a good parent in my state.\u201d 1.\t If the patient complains of respiratory difficulties 4.\t \u201cMy career was important to me before my husband even though vital signs and oxygen saturation are died, but it\u2019s been only 18 months and I don\u2019t feel normal, he is most likely developing delirium. capable of going back to work quite yet.\u201d 2.\t A dying woman with end-stage renal disease should be allowed to choose foods she enjoys even if they are not part of the renal diet. 3.\t The primary goal of end-of-life care is to alleviate suffering and provide the dying person the best quality of life possible. 4.\t Artificial nutrition and hydration may cause a greater burden than benefit to a dying person.","Sexuality and Aging chapter 16\u2003 Objectives http:\/\/evolve.elsevier.com\/Williams\/geriatric 1.\t Develop an understanding of the impact of age on 5.\t Discuss the common concerns of aging lesbian, gay, sexuality. bisexual, and transgender persons. 2.\t Discuss the effects of illness on sexual functioning. 6.\t Select appropriate nursing diagnoses related to sexuality. 3.\t Describe the assessment findings related to sexual 7.\t Describe nursing interventions for older adults functioning of an older adult. experiencing problems with sexuality. 4.\t Identify older people at risk for experiencing problems masturbation\u2002 (m\u0103s-t\u016dr-B\u0100-sh\u016dn, p. 266) related to sexuality. sexual dysfunction\u2002 (p. 261) sexuality\u2002 (s\u0115k-sh\u016b-\u0102L-\u012d-t\u0113, p. 261) Key Terms dyspareunia\u2002 (d\u012ds p\u0115-ROO-n\u0113-\u0103, p. 262) hysterectomy\u2002 (h\u012ds-t\u0115r-\u0114K-t\u014d-m\u0113, p. 263) intercourse\u2002 (\u012cN-t\u0115r-k\u014frs, p. 261) Similar to food and water, sexuality is a basic human components of sexual health. Sexuality is more than need that does not disappear with age. Although just a physical drive; it provides opportunities for the society may prefer to think of older adults as asexual, aging person to express and receive affection, connec- this is not the case. Individuals who have had an active tion, and emotional bonding. Therefore, preserving sex life in younger years are likely to continue to do so sexual health should be an integral part of care for as they age, and many older adults continue to have older adults. sexually satisfying lives well into old age. Nurses have a unique role in the promotion of Women typically lose their childbearing capacity sexual health in older people. The nurse has the respon- after menopause. However, with the assistance of sibility to foster the sexual well-being of older adults reproductive technologies, women can sometimes by offering opportunities for discussion. Open the have healthy children long after their usual childbear- door to discussion of sexual concerns in a nonjudg- ing age. Unlike women, men are generally able to mental manner by offering information and education father children well into their sixties and seventies to those who want to continue being sexually active, without medical assistance. Although uncommon, although making it clear that stopping sex is an accept- fathering children at 80 and 90 years of age does occur. able option for those who choose to do so. Provide Either way, it is important to remember that the loss information and guidance to older people who need it. or decrease in reproductive capacity does not mean the decrease or loss of sexual desires. Even though FACTORS THAT AFFECT SEXUALITY the frequency and form of sexual activity tends to OF OLDER ADULTS change, the sexual needs do not disappear with age (Figure 16-1). Age-related changes have considerable impact on the sexual practices of older adults. Normal physiologic Sexual touching, fondling, masturbation, inter- changes in sexual function may raise concerns for course, and other expressions of sexuality remain an older adults. In general, sexual response time slows important part of the lives of many older people. with aging, but the ability to enjoy various expressions Sexual thoughts and feelings are normal as people age. of sexuality remains throughout life. However, some Studies indicate that more than 65% of individuals changes may have a more significant impact leading aged 65 to 74, and nearly 55% of individuals over the to sexual dysfunction, which is a persistent impairment age of 75 engage in regular sexual activities with a of a person\u2019s usual pattern of sexual functioning. Either partner. The importance of sexuality goes beyond the way, older adults will benefit from holistic care with a biological realm. It also includes psychological, social, focus on promotion of sexual health. and moral dimensions, all of which are essential 261","262\t UNIT III\u2003 Psychosocial Care of Older Adults conditions and treatments that may lead to female sexual dysfunction include uterine prolapse, recto- FIGURE 16-1\u2003 Love and affection are important to older adults. celes, cystoceles, and stress. In many instances, (From Kostelnick C: Mosby\u2019s textbook for long-term care nursing sexual dysfunction resolves when the primary disor- assistants, ed 7, 2015, St. Louis: Mosby.) der is treated. AGE-RELATED CHANGES IN WOMEN Older women experience normal changes in the repro- Complementary and Alternative Therapies ductive system related to the decreased levels of pro- gesterone and estrogen. Approximately one-third of \u2002 women over the age of 65 experience discomfort during intercourse (dyspareunia) related to postmeno- Remedies for Postmenopausal Discomforts pausal changes, such as (1) irritation of the external genitals (pruritus vulvae); (2) thinning and dryness 1.\t Over-the-counter vaginal moisturizers or water-soluble of the vaginal walls (atrophic vaginitis); and (3) altera- lubricants may help decrease the symptoms of dryness. tion in the levels of normal microorganisms in the Vaseline or other petroleum-based products should be vagina, resulting in an increased risk for vaginal yeast avoided. Very-low-dose estrogen preparations in the \t infections. In many instances, dyspareunia can be form of vaginal creams, gels, or rings are sometimes treated with over-the-counter topical preparations (see prescribed to reduce localized symptoms although Complementary and Alternative Therapies). producing minimal systemic effects. In the past, HT was a standard treatment for physi- 2.\t Designer estrogens provide estrogen-like effects on some ologic changes associated with aging. However, a tissues, while blocking the effect of estrogen (acting as an study published by the National Institutes of Health antiestrogen) on other tissues. Tamoxifen and raloxifene (NIH) in 2000 raised serious questions about the safety are two designer estrogens currently in use. of HT, particularly for women who have preexisting cardiovascular or liver disease and those at risk for 3.\t Herbs and other \u201cnatural\u201d remedies are sometimes used breast or endometrial cancer. Many women have made to reduce menopausal symptoms. Because the FDA \t the decision to avoid or discontinue use of HT based has no power to oversee the quality or effectiveness of on this study, but some have decided to accept the anything labeled as a dietary supplement, self-treatment risks and continue to take hormone supplements. Use with herbs may not be a safe practice. If a woman of HT is a personal decision made by each woman with decides to try an herbal remedy, it is essential she tells guidance from her primary care practitioner. Women her physician what she is taking so the physician can who continue to use HT should be carefully monitored monitor her for any untoward effects or possible and have a yearly mammogram and Pap smear. interactions with other prescription and OTC drugs. Dong quai, ginseng, black cohosh, Vitex\/chasteberry, DHEA, Women may experience sexual dysfunction caused melatonin, and St. John\u2019s wort are commonly used herbal by other illnesses, stress, and medications. Medications preparations. such as anticholinergics, antidepressants, and chemo- Other natural products include phytoestrogens and wild therapy may cause arousal disorders. Medications for depression may cause orgasmic disorders. Other yams (sweet potatoes). Phytoestrogens are chemicals that act as estrogens on some parts of the body and antiestrogens\t on others. Soybeans are a rich source of phytoestrogens. Research in this area is ongoing, and more scientific informa- tion is needed. Wild yams are thought to be helpful because they contain a chemical similar to one used for making the type of progesterone in birth control pills. Wild yam creams are considered nonhormonal and are currently being tested for effectiveness. AGE-RELATED CHANGES IN MEN Older men experience a normal delayed reaction to sexual stimuli. They require a longer time to achieve an erection, and the erection is often less firm than it was at a younger age. Male orgasm takes longer to achieve and has a shorter duration than at a younger age. Ejaculation is less forceful and a smaller volume of seminal fluid is released. Loss of erection occurs quickly after orgasm. In general, the time between orgasms increases and orgasm may not occur with every episode of sexual intercourse. The most common sexual dysfunction in older men is erectile dysfunction (ED). ED is the inability to achieve or maintain an erection sufficient for a satisfac- tory sexual intercourse in more than 50% of attempts. Diabetes, depression, and cardiovascular disease con- tribute to ED in men, even at a young age. Prostatectomy","Sexuality and Aging\u2003 CHAPTER 16\t 263 (removal of excess prostate tissue) normally does not Table 16-1\u2003 Examples of Medications and Drugs cause problems with achieving an erection because Associated with Sexual Dysfunction newer surgical techniques do not cause the nerve damage that was common in the past. Medications Antihypertensives Diuretics; alpha and beta adrenergic such as sildenafil citrate (Viagra) or tadalafil (Cialis) blockers; ACE inhibitors; calcium are effective for many individuals suffering from channel blockers erectile dysfunction. CNS medications Monoamine oxidase inhibitors IMPACT OF ILLNESS ON SEXUAL HEALTH (MAOIs); selective serotonin Illness of one or both partners is a common cause of reuptake inhibitors (SSRIs); changes in sexual well-being of older adults. For tricyclic antidepressants; example, joint pain resulting from arthritis can inter- anxiolytics; antipsychotics; lithium fere with sexual activity. Cardiac problems may inter- carbonate, opioids fere with normal sexual activity, although this is often more from fear than from actual danger. The risk for Miscellaneous Anti-seizure medications; cimetidine, serious cardiac problems resulting from sexual inter- methotrexate, estrogens, course is generally low, but older people with history amphetamines, cholesterol- of a heart attack should discuss their concerns with lowering drugs their primary care provider. Sexual activity does not need to be suspended because of stroke, as sex is not OTC medications Some antihistamines, likely to cause another stroke. However, a person with decongestants; antiinflammatories history of stroke may require education about posi- tioning and\/or use of assistive devices to compensate Street drugs Alcohol, cocaine, heroin, tobacco, for any residual weakness or paralysis. Hysterectomy marijuana (removal of the uterus) and mastectomy (removal of a breast) do not change sexual functioning, although FIGURE 16-2\u2003 Loss of intimate partner has a huge impact on the loss of these organs may make the woman feel less sexual health and overall well-being of an older person. (From Black desirable or make her fear that she will be viewed as JM, Hawks JH: Medical-surgical nursing, ed 7, 2005, St. Louis: less desirable. Counseling may be required to help Saunders.) women with these concerns. Chronic depression can decrease sexual interest and lead to decreased response women because single women over the age of 65 out- to intimacy. Finally, it is important to recognize that number single men of the same age by 4\u2009:\u20091. Moreover, incontinence itself does not interfere with physical social norms may suggest to older women that sexual aspect of sexual function but may cause the affected interest in men is not socially acceptable. Older men individuals to avoid sexual activity because of embar- more frequently voice an interest in sex, although rassment. Incontinence treatment and education can older women often express a desire for companionship alleviate or even completely resolve this problem. and love. EFFECTS OF ALCOHOL AND MEDICATIONS ON MARRIAGE AND OLDER ADULTS SEXUAL HEALTH Alcohol and medications can have a profound impact It is commonly believed that older adults think of sex on sexual function in older adults. Excessive alcohol in the context of marriage. This may be no longer true. intake results in delayed orgasm in women and loss of The generation that is now entering retirement age the ability to achieve or maintain an erection in men. A wide range of medications and drugs (Table 16-1) can lead to sexual problems for both men and women. Changes in the medication or the dosage may help resolve the problem. Interestingly, some antiparkinso- nian medications actually enhance sexual desire but not necessarily the ability to perform sexually. LOSS OF A SEX PARTNER Loss of intimate partner is one of the most common causes of decreased sexual activity in older adults (Figure 16-2). Multiple studies identified the inability to find a sexual partner as one of the most frequently stated reason for unsatisfactory sexual life among singles older than 65. This is particularly true for","264\t UNIT III\u2003 Psychosocial Care of Older Adults nonjudgmental attitude and to preserve the therapeu- (i.e., Baby Boomers) matured during a more sexually tic relationship. They need to indicate the willingness experimental time in the U.S. Moreover, it is important to listen and allow adequate time to discuss any con- to be culturally sensitive regarding marriage and sexu- cerns that may arise. ality in a culturally diverse society such as the U.S. SEXUAL ORIENTATION OF OLDER ADULTS Marriage, or remarriage, among older adults garners many different responses, particularly from the fami- The exact number of lesbian, gay, bisexual, and trans- lies of older adults. Some families are accepting and gendered (LGBT) persons over age 65 is unknown. recognize the need for older adults to find affection Studies indicate that about 3 million Americans over and meaning in later life. Others believe that marriage age 65 are LGBT. This figure is expected to double at a late age is somehow unacceptable. Children by 2030. Female LGBT are likely to be overrepre- may fear that the marriage is a slap in the face of the sented in these numbers because of general population deceased parent. They may fear that remarriage will trends and the greater impact of HIV\/AIDS-related displace them from their parent\u2019s affection or affect deaths on the male population. LGBT older people their inheritance. Regardless of the family\u2019s response, face the \u201cdouble stigma\u201d related to their age and older people have the unchallenged right to determine sexual orientation. Health care providers must be what is best for themselves. Ideally, family and friends sensitive to the sexual needs and concerns of the will be supportive of the decision. LGBT older adults. Marriage is not always an option for aging indi- LGBT population still faces considerable discrimi- viduals. Some older people, particularly widows, nation in society. The regulatory protection of the stand to lose a great deal if they remarry. Pensions, rights of LGBT population varies considerably from insurance benefits, and other financial concerns may one jurisdiction to another. Consequently, this popula- be contingent on the person\u2019s remaining single. For tion tends to be underserved, because health care and this reason, some older people choose to live together social services are not always well equipped to provide without marrying. This may be a difficult decision for adequate support to older LGBT people. Many older both older adults and their families because of their LGBT adults are reluctant to access a health care system cultural and religious beliefs. Health care professionals focused on the heterosexual population that often must be able to recognize the value of these relation- fails to address concerns of LGBT community. Older ships and, whenever possible or appropriate, they LGBT persons may be uncomfortable disclosing their should plan and deliver services that will support sexual orientation because of confidentiality concerns older adults\u2019 choices. or fears that discrimination might result in substan- dard care. For example, LGBT older adults may fear CAREGIVERS AND THE SEXUALITY nursing home placement because they are concerned OF OLDER ADULTS that nursing homes may not allow LGBT residents to share a room with their partner, or because they fear Sexuality is a difficult area to address at any age. Young that demonstration of affection between same sex part- people may not be comfortable with the thought ners will be viewed negatively. Many aging LGBT of sexual activity among seniors, believing that it is people report becoming depressed and express concern somehow offensive or abnormal. Similarly, health pro- about having to deny or conceal their life choices to fessionals may harbor personal biases or may lack nec- gain acceptance. Nurses are expected to promote essary skills to address the sexual needs of older adults sexual well-being of all older adults regardless of their in a therapeutic manner. In addition, older adults sexual orientation. Developing services sensitive to the are often reluctant to discuss their own sexuality. needs of LGBT population is an important goal for Discomfort or embarrassment over what younger health care. persons may think causes many older people to hide their sexual interests and activity even from health SEXUALLY TRANSMITTED DISEASE professionals. Nurses and other health professionals who provide care to older adults must be nonjudg- Older adults often are not considered when sexually mental and sensitive to the values and attitudes of transmitted diseases (STD) are discussed even though older individuals. nearly 20% of all HIV\/AIDS cases in the U.S. are people older than 50. Human immunodeficiency virus Caregivers should address issues of sexuality in (HIV) is commonly overlooked because older adults private and ask open-ended questions such as, \u201cAre are not considered to be at high risk for HIV infection. you concerned about how your sexuality has changed This is one of the possible reasons why the incidence with age?\u201d or \u201cAre you satisfied with your sex life?\u201d of HIV in older people is rising faster than in those of Open-ended questions allow the older person the 24 years of age and younger. The prevalence of HIV opportunity to express a variety of concerns in their among older adults is likely to continue to increase as own words and the manner that is acceptable to them. Caregivers must be aware and maintain the control of their own personal and cultural beliefs to maintain","Sexuality and Aging\u2003 CHAPTER 16\t 265 more individuals become infected later in life, and PRIVACY AND PERSONAL RIGHTS individuals infected in early adulthood live longer as OF OLDER ADULTS a result of better disease treatment. Moreover, the Community-dwelling older adults generally have a decreasing responsiveness of immune system associ- right to manage their sex lives without interference. ated with aging increases older persons\u2019 susceptibility They are free to express affection and engage in sexual to HIV and AIDS. AIDS in older adults is known as the activities whenever they choose. However, institu- \u201cGreat Imitator\u201d because many of the associated symp- tional placement of one or both partners may interfere toms are similar to other diseases and may be attrib- with their ability to maintain their usual sexual pat- uted to normal aging. Older adults with HIV are at terns. Finding privacy may be difficult, even for higher risk of cognitive decline. Dementia associated married couples who reside in the same institution, with AIDS may be mistaken for Alzheimer disease. particularly if regular medical or nursing care is neces- The threat of other STDs is equally important. Between sary (Figure 16-3). 2007 and 2011, chlamydia infections among the age 65+ group rose 31%, and the rate of syphilis increased 52%, In the past, displays of sexual affection were dis- trends that are similar to people age 20 to 24 (Emanuel, couraged among older adults. This is slowly changing 2014). People are living longer and are in better health, as health care professionals continue to develop their and retirement communities, much like college cam- understanding of the importance of sexual well-being puses, provide ample opportunities for sexual activity. across the lifespan. Many facilities and clinical agen- Additionally, today\u2019s older adults were raised in an era cies now have policies and programs that protect and before \u201csafer sex\u201d practices became the norm. Activities promote expression of sexuality among older adults. promoting sexually responsible behaviors should Touching, handholding, and cuddling are encouraged. target older adults, as the risk of STD clearly does not Unmarried older adults are allowed to form whatever disappear with age. relationships they desire. A closed door must be respected when privacy for intimacy is desired. Of Cultural Considerations course, judgment is necessary when either person in a relationship suffers from cognitive impairment. When \u2002 there is any sign of disinterest or resistance to sexual advances, the behavior is not permitted. It is important HIV and Older Adults to protect vulnerable older adults from undesired physical contact, but mutually agreeable physical In a study done with African American, Chinese American, contact should remain a right of older adults. Latino, and white participants, it appears that regardless of their cultural group, older adults tend to perceive or verbalize NURSING PROCESS FOR SEXUAL DYSFUNCTION that HIV is a problem of someone else, not themselves. Common misconceptions were present in all groups. Although \u2002 most did not think HIV actively involved them, they were, in general, willing to learn about it to \u201cteach their children or ASSESSMENT\/DATA COLLECTION grandchildren.\u201d Several older African Americans stated that they thought HIV was less of a problem now and that older \u2002 adults were most likely to contract HIV through contact with doctors, dentists, and hospitals. Drug use and sexual activity \u2022\t Is the person sexually active? were viewed as much less likely sources. Latina women had \u2022\t If the person is sexually active, do they have any difficulty accepting that HIV occurred in older adults. Chinese Americans, though apparently knowledgeable regarding HIV, difficulties or discomfort during sexual activity? expressed views that a stable life, good diet, and exercise \u2022\t Does the person have any discharge or drainage could prevent HIV. White participants supported the belief that HIV was a young person\u2019s disease. Older adults in all cultural from the genitals? groups were reluctant to discuss the use of condoms. Health Promotion FIGURE 16-3\u2003 Much can be said with a touch. (From Kostelnick C: Mosby\u2019s textbook for long-term care nursing assistants, ed 7, 2015, \u2002 St. Louis: Mosby.) Health Care Directives for Nonrelated Caregivers LGBT people need to be aware of the laws regulating same- sex relationships in their respective states. In the states that do not provide protection to same-sex relationships, LGBT people may need to be made aware of the importance of completing advance care directives if they wish to have their friends, partners, or other nonfamily members participate in health care decision making. Without these directives, even long-term partners may not have legal standing in decision making and may even be prohibited from visiting in some situations.","266\t UNIT III\u2003 Psychosocial Care of Older Adults anyone, including nurses. Without undue prying into the older person\u2019s privacy, communicate a will- Box 16-1\u2003 Risk Factors Related to Sexual Dysfunction ingness to discuss any concerns older adults have, in Older Adults including those that deal with sexuality. Allow ade- quate time and provide a private place for these \u2022\t Loss of partner discussions. \u2022\t Problems with physical mobility 2.\t Provide privacy. Older adults who wish to court or \u2022\t Institutional setting visit should have the opportunity to do so without \u2022\t Physical illness or a reaction to therapeutic interference. Private areas should be available for dating interactions. Older residents of extended- medications care facilities should have the opportunity for con- jugal visits in the institution or at home if desired. \u2022\t Does the person have any diseases or disabilities Ensure that these visits meet all federal and state that interfere with sexual activity? regulations that pertain to residents\u2019 rights. Carefully respect privacy during these visits. \u2022\t Are there any emotional issues, such as depression, 3.\t Protect the sexual dignity of confused older adults. that interfere with sexual interest or activity? Confused individuals may display sexually inap- propriate behaviors (e.g., exposing themselves in \u2022\t Does the person take any medications that may public, masturbating, and making inappropriate interfere with sexual activity? sexual advances to nursing staff). Implement inter- ventions to protect their dignity. For example, \u2022\t What level of sexual activity does the person desire? undressing in public can be decreased by modifying \u2022\t Does the person have any real or perceived barriers clothing. For men, elastic-waist pants can replace pants with zippers. For women, buttonless or to sexual activity? back-opening tops and slacks instead of skirts \u2022\t Does the person have adequate privacy for sexual can help reduce exposure. Masturbation is common and is not abnormal. Distraction is often effective at activity? reducing the incidence of public masturbation. If Box 16-1 lists risk factors for sexual dysfunction in distraction is not effective, take the person to his older adults. or her room and provide privacy. Do not apply restraints to prevent masturbation. If a confused NURSING DIAGNOSIS older person makes inappropriate sexual advances, attempt to distract them and, if necessary, stop care \u2002 temporarily. Confused individuals do not realize that their behavior is inappropriate. Do not over- Sexual dysfunction react to the behavior, because this can precipitate violent or verbally abusive episodes (Nursing Care NURSING GOALS\/OUTCOMES IDENTIFICATION Plan 16-1). \u2002 The nursing goals for older adults with sexual dys- function are to (1) verbalize feelings about sexual iden- tity; (2) discuss concerns regarding sexuality; and (3) describe the effects of aging and illness on sexual functioning. NURSING INTERVENTIONS\/IMPLEMENTATION \u2002 The following nursing interventions should take place in hospitals, in extended-care facilities, and at home: 1.\t Encourage verbalization of concerns. Many older adults do not feel comfortable talking about sex to \u2002 Nursing Care Plan\u2002 16-1\u2003 Sexual Dysfunction Mr. Silver, age 89, has a history of hypertension and diabetes. Mrs. Silver, age 87, has severe osteoarthritis and congestive heart failure. Both are residents of Pine Grove Care Center. They have been married for 67 years. Because of space constraints, they have been assigned to separate rooms. Mr. Silver spends a great deal of time at Mrs. Silver\u2019s bedside, where he holds her hand and talks to her. Both often verbalize the wish to hold and touch more intimately. They both state, \u201cI wish we just had some privacy around here.\u201d NURSING DIAGNOSIS Sexual Dysfunction DEFINING CHARACTERISTICS \u2022\t Lack of privacy \u2022\t Separation from significant other \u2022\t Altered body function related to age and disease processes PATIENT GOALS\/OUTCOMES IDENTIFICATION Mr. and Mrs. Silver will identify methods for satisfying their need for sexual expression.","Sexuality and Aging\u2003 CHAPTER 16\t 267 \u2002 Nursing Care Plan\u2002 16-1\u2003 Sexual Dysfunction\u2014cont\u2019d NURSING INTERVENTIONS\/IMPLEMENTATION 1.\t Allow opportunities for both parties to verbalize their feelings about continuing sexual contact. 2.\t Attempt to arrange for a shared room, if this is agreeable to both parties. 3.\t Develop a method, such as hanging a \u201cDo Not Disturb\u201d sign, for ensuring private time for the couple, while recognizing the need for access in case of emergency. 4.\t Assist with hygiene needs so that both parties are physically clean and attractive. 5.\t Verbalize an understanding of the continued need for physical closeness throughout life. EVALUATION Mr. and Mrs. Silver are observed spending time privately in Mrs. Silver\u2019s room with the door closed. After these visits, Mr. Silver states that \u201cIt feels good just to touch, share a kiss, and be together quietly for a while. It isn\u2019t how I thought we\u2019d end up, but it\u2019s better than nothing.\u201d You will continue the plan of care. CRITICAL THINKING QUESTIONS 1.\t Some facilities permit or encourage married couples to share a room in long-term care facilities. 2.\t Do you think that this is something that should be encouraged or discouraged? Why? 3.\t How can the nurse provide for privacy needs if a couple is still interested in sexual activity? How can the nurse determine whether there is mutual consent to sexual activity? Get Ready for the NCLEX\u00ae Examination! 2.\t A 69-year-old woman reports that she avoids intercourse because it is uncomfortable. She asks \t Key Points the nurse if she has any suggestions to relieve this problem. What should the nurse do? \u2022\t Sexuality is an area that is often minimized or ignored 1.\t Suggest that she ask the physician for an estrogen in older adults. vaginal cream. 2.\t Describe herbal and natural products that have \u2022\t Older adults have the right to make decisions about effects similar to estrogen. their sexuality. 3.\t Clarify what she means by \u201cuncomfortable.\u201d 4.\t Explain that this is a normal and expected change \u2022\t Health problems, loss of a partner, and the normal of aging. physiologic changes of aging all affect sexual practices. 3.\t An older gentleman who suffers from dementia \u2022\t Age- and health-related changes affect the type and often masturbates in the lounge area of a long-term frequency of sexual activity, but many individuals care facility. Which nursing interventions would be maintain an active interest in sex into old age. appropriate? (Select all that apply.) 1.\t Modify clothing to make genital exposure more \u2022\t Nurses must recognize that older adults are still sexual difficult. beings, and they continue to have sexual needs. 2.\t Apply mitten restraints to prevent self-stimulation. 3.\t Provide privacy by escorting him back to his room. \u2022\t Nurses must respect and protect older adults\u2019 right to 4.\t Explain repeatedly that this type of behavior is not enjoy sexual activities that meet their needs without acceptable. age bias. 5.\t Distract him with an activity that he finds interesting. 6.\t Administer a prn sedative medication. \u2022\t Information about safer sex should be available to older adults, as STD rates are on the rise in this age group. 4.\t Why might an older gay person be reluctant to move into a long-term care facility? Additional Learning Resources 1.\t Fears that he will receive substandard care 2.\t Prefers not to associate with aging heterosexuals \u2002 Go to your Evolve website at http:\/\/evolve.elsevier 3.\t Understands that he will lose legal rights in the .com\/Williams\/geriatric for the additional online resources. facility 4.\t Knows that most caregivers will discriminate against Review Questions for the NCLEX\u00ae Examination him 1.\t A 70-year-old married man confides to the nurse that he recently began to have difficulty achieving an erection. He states that, \u201cIt wasn\u2019t much of a problem until recently.\u201d What would be the nurse\u2019s best response? 1.\t \u201cThat\u2019s quite normal at your age.\u201d 2.\t \u201cWhat do you think is wrong?\u201d 3.\t \u201cAre you having problems in your marriage?\u201d 4.\t \u201cDid you recently change any medications?\u201d","268\t UNIT III\u2003 Psychosocial Care of Older Adults 3.\t \u201cMr. Nguyen told me that he does not feel comfortable discussing his sexual issues with me. 5.\t The nurse is precepting new grad LVN at a nursing Should I ask his son to talk to him and relay the home. Which statement by the new grad indicates \t content of their conversation to me?\u201d that she has good understanding of sexuality in aging population? 4.\t \u201cMrs. Ball told me that she has been \u2018toying with the 1.\t \u201cMr. Wang and Mrs. Levy would like some privacy idea\u2019 of marrying her long-term companion. Should \t while they are in Mrs. Levy\u2019s room. Would it be OK I warn her against it because it might upset her to place a \u2018Do Not Disturb\u2019 sign on her room door?\u201d children?\u201d 2.\t \u201cMr. Smith was masturbating in his bed yet again this morning. I asked him to refrain from doing it because it makes the staff uncomfortable.\u201d","Unit IV\u2003 Physical Care of Older Adults chapter Care of Aging Skin and Mucous Membranes 17\u2003 Objectives http:\/\/evolve.elsevier.com\/Williams\/geriatric 1.\t Discuss changes related to aging that have an effect on 3.\t Describe interventions that assist older adults in skin and mucous membranes. maintaining intact skin and mucous membranes. 2.\t Identify the older adults who are most at risk for problems hyperkeratosis\u2002 (h\u012b-p\u0115r-k\u0115r-\u0103-T\u014c-s\u012ds, p. 275) related to the skin and mucous membranes. leukoplakia\u2002 (l\u016b-k\u014d-PL\u0100-k\u0113-\u0103, p. 284) pigmentation\u2002 (p\u012dg-m\u0115n-T\u0100-sh\u016dn, p. 271) Key Terms pressure ulcers\u2002 (p. 269) pruritus\u2002 (pr\u016b-R\u012a-t\u016ds, p. 269) alopecia\u2002 (\u0103l-\u014d-P\u0112-sh\u0113-\u0103, p. 275) scabies\u2002 (SK\u0100-b\u0113z, p. 271) aseptic\u2002 (\u0101-S\u0114P-t\u012dk, p. 280) shearing forces\u2002 (p. 272) caries\u2002 (K\u0102R-\u0113z, p. 283) xerostomia\u2002 (z\u0113r-\u014d-ST\u014c-m\u0113-\u0103, p. 283) dysgeusia\u2002 (d\u012ds-go\u00f3zhah, p. 286) edentulous\u2002 (\u0113-d\u0115n-ch\u016b-l\u016ds, p. 283) exudate\u2002 (\u0114KS-\u016b-d\u0101t, p. 277) gingivitis\u2002 (j\u012dn-j\u012d-V\u012a-t\u012ds, p. 283) halitosis\u2002 (h\u0103l-\u012d-T\u014c-s\u012ds, p. 283) The skin undergoes several changes with aging that situations in which the problems are not preventable, make it more susceptible to damage. Over time, the they should be recognized, treated, and resolved in a epidermal layer becomes thinner and the subcutane- timely manner. ous padding diminishes, increasing the risk for trau- matic injuries such as skin tears or pressure ulcers. AGE-RELATED CHANGES IN SKIN, HAIR, Bruises are more common because capillary walls are AND NAILS more fragile. Skin tears can turn into chronic wounds if not treated properly. Medications used to treat Changes in the skin, hair, and nails may indicate a various health problems can cause problems. Corti\u00ad variety of problems related to nutritional and circula- costeroids make the skin more fragile, and anticoagu- tory adequacy. Because these structures are the ones lants increase the risk for bleeding with even minor most easily observed, they can provide a great deal of trauma. Decreased sebaceous secretions and circula- information about the metabolic health of the entire tory changes contribute to the dry skin and scaliness body. See Table 17-1 for a complete delineation of these of the lower extremities common with aging. Aging changes. skin is more susceptible to inflammation, infection, and rashes. Pruritus (itching), which is a common com- Complete assessment of skin, hair, and nails is best plaint in older adults, may be caused by dryness, irrita- done when the person is undressed so that all skin tion, or infection but can be related to diseases such surfaces can be inspected. Skin assessment can be per- as diabetes mellitus, kidney disease, malignancy, or formed during a bath, during daily personal hygiene, anemia. Changes in the function of dermal receptor at bedtime, or at any other convenient time for the cells result in a decrease in the ability of the older older person. Independent older adults should be person to perceive sensations such as touch and pres- aware of what is normal for themselves, and they sure, increasing the risk for pressure-related disorders. should bring any changes to the attention of the Although skin problems usually are not life threaten- primary care provider. In a hospital or extended-care ing, they are significant because they can distress the setting, privacy must be maintained and modesty pro- older person and lead to decreased quality of life. Skin tected during the skin inspection. Assessment of the problems should be prevented whenever possible; in skin and related structures is an important responsibil- ity of nurses. Instruct nursing assistants and attendant 269","270\t UNIT IV\u2003 Physical Care of Older Adults Table 17-1\u2003 Age-Related Changes in Skin, Hair, and Nails Hair AGE-RELATED CHANGE RELATED ASSESSMENT FINDINGS Color Decreased production of melanin Graying of hair Texture Many hair follicles stop producing; as hair falls Thinner hair out less is replaced Decreased axillary, pubic, and extremity hair; increased Distribution Hormonal changes facial hair in women Nails Nail plate growth rate decreases Slower growing nails Growth Nail plate morphology changes Thick or thin nails; brittle, discolored nails Texture, color Skin Thinning of the epidermis Thinner, more translucent skin Appearance Fewer melanocytes; remaining melanocytes Paler looking skin; large pigmented spots (\u201cage spots\u201d) Sensation\/Safety tend to be larger More frequent bruising, cherry angiomas Fragile blood vessels in the dermis Dry skin Decreased oil production by sebaceous glands Feeling \u201ccold\u201d; risk of developing hypothermia Decreased subcutaneous fat Harder to keep cool in hot weather; risk of Decreased production of sweat by sweat hyperthermia glands Data from Abdullah L, Abbas O: Common nail changes and disorders in older people. Canadian Family Physician, 57(2):173\u2013181, 2011; Dugdale DC: Aging changes in hair and nails. 2012. http:\/\/www.nlm.nih.gov\/medlineplus\/ency\/article\/004005.htm; Dugdale DC: Aging changes in skin. 2012. www.nlm.nih.gov\/medlineplus\/\t ency\/article\/004014.htm; Jett K: Physiologic changes. In Touhy TA, Jett K: Ebersole and Hess\u2019 toward healthy aging: Human needs and nursing response. 2012, St. Louis: Elsevier Mosby. SKIN COLOR Changes in skin color can indicate a variety of disor- ders. When assessing skin for color, it is important to be aware of the differences in skin pigments among ethnic groups. Examine the skin in good, preferably natural, light; compare one side of the body with the other; and use touch to determine skin temperature or the presence of rashes or irritation. Stretching the skin slightly may help in determining the underlying tones. Color changes, including pallor, cyanosis, jaundice, or erythema, can indicate a variety of problems. Record and report the extent and location of any color changes promptly. FIGURE 17-1\u2003 Example of a body diagram that can be used in Cultural Considerations assessing older patients for skin impairment. (From Sorrentino SA: Mosby\u2019s textbook for nursing assistants, ed 6, 2004, St. Louis: \u2002 Mosby.) Pressure Ulcers When assessing people with dark skin tones, changes in tissue color that indicate stage I pressure ulcers can be better distin- guished using a halogen light, which may reveal a purple hue. Be sure to use touch to determine changes in tissue tempera- ture or sensation and palpate for signs of localized edema over pressure points. healthcare workers who assist with bathing or other DRY SKIN care to promptly report any unusual or questionable Dry skin is one of the most common problems of aging. observations to a nurse for further investigation. Studies have shown that 75% of people older than 65 Inspection should follow a logical order so that no years of age experience dry skin. Physiologic changes, pertinent observations are missed. Most nurses find excessive bathing, the use of harsh soaps, and a dry that a head-to-toe progression is the most helpful, as environment all contribute to problems with dry skin. is a body diagram on which observations are indicated (Figure 17-1). Dry skin can result in itching (pruritus), burning, and cracking of the skin (Figure 17-2). Older people","Care of Aging Skin and Mucous Membranes\u2003 CHAPTER 17\t 271 FIGURE 17-2\u2003 Dry, scaly skin commonly seen in older adults. (From FIGURE 17-4\u2003 Scabies lesions at three different stages are evident White GM, Cox NH: Diseases of the skin: A color atlas and text, on this patient\u2019s hand. The lesion at the far left features a well- demarcated round border surrounding a blister, whereas the lesion ed 2, 2006, St. Louis: Mosby.) nearest the thumb fold has already erupted and appears to be healing. (From White GM, Cox NH: Diseases of the skin: A color atlas and text, ed 2, 2006, St. Louis: Mosby.) FIGURE 17-3\u2003 Drug-induced skin reactions are seen more commonly infection caused by a parasitic mite (Sarcoptes scabiei among older patients than in younger patients. Use of a potent var. hominis) that burrows under the skin (Figure 17-4). topical corticosteroid has resulted in severe striae. The atrophy was Older adults, especially individuals who suffer from so severe that the skin tore, forming an ulcer. (From White GM, \t chronic illness, dementia, or a depressed immune Cox NH: Diseases of the skin: A color atlas and text, ed 2, 2006, system, are particularly vulnerable to scabies infec- St. Louis: Mosby.) tions. Signs of scabies include intense itching and fine, dark, wavy lines at the flexor surface of the wrist or may develop a habit of scratching or picking at dry or elbow, the webbed area of the fingers, the axilla, and cracked skin, increasing their risk for further tissue the genitals. Recognition of scabies may be difficult in damage and infection. Skin irritation can be severe and older adults because it has an asymptomatic incuba- can cause intense discomfort to older adults. In fact, it tion period of 4 to 6 weeks and because atypical pre- may be so distracting that affected individuals stop sentations are common. When infestation is suspected, participating in social activities. skin scrapings should be examined to determine the presence of ova or mites. RASHES AND IRRITATION Rashes and skin irritation can be caused by factors Scabies is spread from person to person by direct other than dryness. Medications, communicable dis- contact. Because recognition is difficult, treatment may eases, and contact with chemical substances are com\u00ad be delayed, allowing the parasite to infect other people. mon causes of skin rashes and pruritus (Figure 17-3). To reduce outbreaks of scabies infection within an institution, all new residents in extended-care settings Allergic response to medications can manifest as should be assessed carefully on admission. All cases diffuse rashes over the body. Whenever a rash devel- must be identified and treated promptly to prevent ops soon after administration of new medication, a spread or reinfestation with the parasite. drug allergy should be suspected. It is appropriate to withhold that particular medication and contact the PIGMENTATION primary care provider to report the symptom. Changes in skin pigmentation are common with aging (see Chapter 3). Many of the changes are cosmetic One communicable source of skin irritation and and do not cause problems unless they are located on severe pruritus is scabies. Scabies is a superficial the face or arms, where they may be distressing to the affected person. Common conditions such as acne rosacea can be treated with topical medications, which help heal the skin and reduce redness, whereas others can be concealed by appropriate use of cosmetics. Changes in the size or pigmentation of moles are of greater significance and must be reported because these changes may indicate the presence of a precan- cerous or cancerous condition that needs immediate medical attention.","272\t UNIT IV\u2003 Physical Care of Older Adults Table 17-2\u2003 Quick Guide to Prevention of Pressure Ulcers RISK FACTOR NURSING INTERVENTIONS Immobility Establish individualized turning schedule; reduce shear and friction by using trapeze and\/or Inactivity turning sheet; elevate HOB <30 degrees; provide pressure-relief surface Provide assistive devices to increase activity Incontinence Assess the need for incontinence management; clean and dry skin after soiling Malnutrition Provide adequate nutritional and fluid intake; assist with snacks and meals, monitor intake and output (I&O); consult the dietitian for nutritional evaluation Diminished sensation, Assess the patient\u2019s and family\u2019s ability to provide care; educate caregivers regarding pressure decreased mental status ulcer prevention Impaired skin integrity Avoid pressure; do not use donut-shaped cushions or sheepskin; lubricate skin; apply barrier ointments to protect skin from moisture; do not massage red areas; do not use heat lamps, heating pads, or hot water Modified from Catania K et\u202fal: PUPPI\u2014The pressure ulcer prevention protocol interventions. Am J Nurs, 107(4):44\u201352, 2007. TISSUE INTEGRITY involved. Tissue that is subjected to excessive pressure Breaks in tissue integrity increase the older person\u2019s does not receive adequate oxygen or nutrients. This risk for infection and often result in the need for costly, can result in ischemia and increased susceptibility to time-consuming treatments. These breaks can cause breakdown. When tissue is deprived of necessary disfigurement and are frightening to older adults. Skin nutrients for a longer period, necrosis and tissue tears, abrasions, lacerations, and ulcers most often destruction is the result. Tissue that is fragile because result from pressure or pressure combined with shear- of poor nutrition or circulation is most susceptible to ing forces. Even simple incidents such as bumping a breakdown. Early danger signs indicating a risk for leg into an open dishwasher door, sliding across bed breakdown include pale or reddened tissue. Pressure linens, or the removal of tape may result in significant ulcers are categorized or staged based on their appear- skin trauma to the older person. ance and the depth of tissue penetration (Figure 17-6). PRESSURE ULCERS Individuals who have had one pressure ulcer are Pressure ulcers are a particular risk to older adults who at greater risk for future development of additional suffer from compromised circulation, restricted mobil- ulcers. Additional factors that contribute to develop- ity, altered level of consciousness, fecal or urinary ment of pressure ulcers include the following: incontinence, or nutritional problems (Table 17-2). \u2022\t Obesity Studies estimating the occurrence of pressure ulcers \u2022\t Malnutrition vary widely, but one consistent point is that they occur \u2022\t History of alcohol and tobacco use in all settings. Although most studies show that the \u2022\t Edema incidence of pressure ulcers has declined, there is still \u2022\t Moisture: bladder and\/or bowel incontinence, use much work to do regarding prevention. Pressure ulcers have negative effects on the overall health of an older of incontinence briefs adult. They can lead to infection, pain, loss of function, \u2022\t Immobility and even death. Furthermore, incidence of pressure \u2022\t Shearing forces ulcers can leave care facilities and nurses vulnerable to \u2022\t Cognitive impairment lawsuits for negligence. A single pressure ulcer can It is recommended to perform a formal risk assess\u00ad cost up to $40,000 to treat, and that does not include ment at the time of admission, upon discharge, upon the human cost of pain and suffering. New Medicare any change in patient condition, and then at regular rules specify that a hospital will not be reimbursed for intervals. Guidelines recommend that this assessment the care of a patient who develops a \u201creasonably pre- include a complete history and physical examination, ventable\u201d pressure ulcer after being admitted to a hos- skin inspection, and use of a pressure ulcer risk assess- pital. In some states, it is mandatory to report the ment tool (Ayello & Sibbald, 2012). The most common development of a stage III or IV pressure ulcer to the tools used for this assessment are the Braden and Department of Health. It is important to carefully Norton Scales (Tables 17-3 and 17-4). Nurses use the assess and document any pressure ulcers that are information from this assessment to develop a plan of present upon admission. care that minimizes risk factors and promotes skin integrity. Excessive pressure on tissues, particularly over bony prominences, can quickly lead to skin break- AMOUNT, DISTRIBUTION, APPEARANCE, down (Figure 17-5). Ulcer development depends on AND CONSISTENCY OF HAIR the amount of pressure, the length of time pressure is The amount, distribution, appearance, and consistency exerted, and the underlying status of the tissues of the hair change with aging. Hair typically becomes thinner and has a finer consistency with advanced age.","Care of Aging Skin and Mucous Membranes\u2003 CHAPTER 17\t 273 Pressure ulcer sites Anterior Posterior 1 1 Occipital bone Chin Occiput 2 Scapula P Su 2 4 3 Spinous process Scapula 3 4 Elbow Trochanter Su 5 2 5 Iliac crest L Elbow 6 6 Sacrum Knee Si Su 6 7 Ischium P Spinous process 7 7 8 Achilles tendon Su 9 Heel Pretibial crest 8 22 10 Sole P Ischium 10 9 10 11 Ear Si 12 Shoulder Key 11 13 22 13 Anterior iliac spine P = Prone position Malleolus 12 14 16 19 14 Trochanter Su = Supine position L 15 17 18 20 21 15 Thigh Si = Sitting position 16 Medial knee Heel 17 Lateral knee A L = Lateral position Su 18 Lower leg 19 Medial malleolus B 20 Lateral malleolus 21 Lateral edge of foot 22 Posterior knee FIGURE 17-5\u2003 A, Bony prominences most often underlying pressure ulcers. B, Pressure ulcer sites. L, lateral position; P, prone position; Si, sitting position; Su, supine position. (A-B, From Trelease CC: Developing standards for wound care. Ostomy Wound Manage, 26:50, 1988.) A Stage I D Stage IV B Stage II E Unstageable C Stage III F Suspected deep tissue injury FIGURE 17-6\u2003 Stages of pressure ulcers. A = Stage I; B = Stage II; C = Stage III; D = Stage IV; E = Unstageable; F = Suspected deep tissue injury. (Used with permission from the National Pressure Ulcer Advisory Panel.)","274\t UNIT IV\u2003 Physical Care of Older Adults Table 17-3\u2003 Braden Scale for Predicting Pressure Sore Risk ASSESSMENT TOOL 1 POINT 2 POINTS 3 POINTS 4 POINTS Sensory Perception Completely limited: Very limited: Slightly limited: No impairment: Unresponsive (does not Responds only to painful Responds to verbal Responds \t Ability to respond commands but to verbal meaningfully to moan, flinch, or grasp) stimuli; cannot cannot always commands; has pressure-related to painful stimuli communicate communicate no sensory discomfort because of diminished discomfort except by discomfort or the deficit that could level of consciousness moaning or need to be turned limit ability to feel or sedation restlessness or voice pain or Or discomfort Or Or Has some sensory Limited ability to feel pain Has a sensory Rarely moist: Skin impairment, which is usually dry; over most of body impairment that limits limits ability to feel linen requires surface or discomfort the ability to feel pain pain or discomfort changing only at over half \t on one or two routine intervals of body extremities Occasionally moist: Skin is occasionally Walks frequently: Moisture moist, requiring an Walks outside extra linen change room at least Degree to which Constantly moist: Skin is Very moist: Skin is often, approximately once a twice a day and skin is exposed kept moist almost but not always, moist; day inside room at to moisture constantly by linens must be least once every perspiration, urine, and changed at least once Walks occasionally: 2 hours during the like; dampness is a shift Walks occasionally waking hours detected every time during day, but for patient is moved or very short distances, No limitations: turned with or without Makes major and assistance; spends frequent body Activity majority of each shift position changes on bed or chair without Degree of Bedridden: Confined to Chairfast: Ability to walk assistance severely limited or Slightly limited: Makes physical activity bed nonexistent; cannot frequent although Excellent: Eats bear own weight and\/ slight changes in most of every or must be assisted body or extremity meal; never into chair or position refuses meal; wheelchair independently usually eats total of four or more Mobility Completely immobile: Very limited: Makes Adequate: Eats more servings of meat Does not make even occasional slight than half of most and dairy Ability to change slight light changes in changes in body or meals; eats a total \t products per and control body or extremity extremity position but of four servings of day; occasionally body position position without is unable to make protein (meat or dairy eats between assistance frequent or significant products) each day; meals, does \t changes independently occasionally refuses not require Nutrition Very poor: Never eats a meal, but usually supplements complete meal; rarely Probably inadequate: takes a supplement if Usual food intake eats more than one Rarely eats a complete offered pattern third of any food meal; generally eats offered; eats two only approximately half Or servings or less of of any food offered; Is on a tube feeding or protein (meat or dairy protein intake includes products) per day; only three servings of total parenteral takes fluids poorly; meat or dairy products nutrition regimen that does not take a liquid per day; occasionally probably meets most dietary supplement takes a dietary of nutritional needs supplement Or Receives nothing by Or Receives less than mouth and\/or is maintained on clear optimal amount of liquids or intravenous liquid diet or tube fluids feeding solutions for more than 5 days","Care of Aging Skin and Mucous Membranes\u2003 CHAPTER 17\t 275 Table 17-3\u2003 Braden Scale for Predicting Pressure Sore Risk\u2014cont\u2019d ASSESSMENT TOOL 1 POINT 2 POINTS 3 POINTS 4 POINTS Friction and Shear No apparent problem: Problem: Requires Potential problem: Moves Moves in bed and in moderate to maximal feebly or requires chair independently assistance in moving; minimal assistance; and has sufficient complete lifting without during a move, skin muscle strength to sit sliding against sheets is probably slides to up completely during impossible; frequently some extent against move; maintains slides down in bed or sheets, chair, restraints, good position in bed chair, requiring frequent or other devices; or chair at all times repositioning with maintains relatively maximal assistance; good position in chair spasticity, contractions, or bed most of the time or agitation leads to but occasionally slides almost constant friction down From Bergstrom N et\u202fal. The Braden scale for predicting pressure sore risk. Nursing Research, 36(4):205\u2013210, 1987. Instructions: Score patient in each of the six subscales. The maximum score of 23 has the best prognosis, and the minimum score of 6 has the worst prognosis. A patient is at risk for pressure ulcer if the \t score is \u226416. Table 17-4\u2003 Norton Risk Assessment Scale PHYSICAL CONDITION MENTAL CONDITION ACTIVITY MOBILITY INCONTINENT TOTAL SCORE 4 Full 4 Not 4 Good 4 Alert 4 Ambulant Fair 3 Apathetic 3 Walk\/help 3 Slightly limited 3 Occasional 3 Poor 2 Confused 2 Chairbound 2 Very limited 2 Usually\/Urine 2 Very bad 1 Stupor 1 Bed 1 Immobile 1 Doubly 1 Name Date From Norton et\u202fal. An investigation of geriatric nursing problems in the hospital, published in 1962 by the National Corporation for the Care of Old People. Reproduced with permission from the Centre for Policy on Ageing, London (formerly NCCOP). Heredity and gender play a role in hair loss patterns. Hammertoe Men tend to lose more hair than do women, although Ingrown some men retain a full head of hair throughout life. nail Male pattern baldness typically results in progressive loss of hair at the temples and back of the head. Sudden Gout Toenail and excessive hair loss (alopecia) or breakage is likely fungus to indicate a systemic problem. Abnormal hair loss can be related to high fevers, medications, nutrition prob- Bunion Metatarsalgia Corn lems, fungal or bacterial infections, endocrine disor- Callus ders, or stress. Sudden or unusual hair loss should be reported so that the primary care provider can deter- FIGURE 17-7\u2003 Common foot problems in older adults. (From Ebersole mine the cause. P, Hess P: Toward healthy aging: Human needs and nursing experience, ed 7, 2008, St. Louis: Mosby.) The amount and distribution of body hair also change with aging. Diminished or absent hair on the inspection. Many older adults neglect their feet simply lower legs or feet, particularly when combined with because they cannot see or reach them. Unless foot excessively dry, scaly, or flaky skin and weak or absent inspection is done on a regular schedule, severe prob- pedal pulses, indicates decreased blood supply to the lems can occur before anyone is aware of them. lower extremities. Nails Tissue of the Feet Aging results in hyperkeratosis of the nails, particu- Inspection of the tissue on the feet warrants special larly the toenails. Thick, hard nails are difficult to cut attention in older adults. Because many aging indi- using normal foot care equipment. The strength and viduals are unable to bend adequately to view the feet, a family member or friend can perform this inspection for independent older adults (Figure 17-7). In an insti- tutional setting, nursing staff should perform foot","276\t UNIT IV\u2003 Physical Care of Older Adults Box 17-1\u2003 Risk Factors for Alterations in Skin, Hair, or Nails in Older Adults effort required to cut these nails may exceed the older person\u2019s abilities, resulting in overgrowth. Soaking the \u2022\t Circulatory problems feet in warm water before attempting to cut them may \u2022\t Restricted mobility soften the nails and make them easier to cut. Assistance \u2022\t Nutritional or fluid imbalances from a family member or health care provider is appro- \u2022\t Cognitive impairments priate when there is no history of circulatory problems \u2022\t Exposure to irritating chemicals, including body or diabetes. When diabetes or circulatory problems are present, care should be provided by a foot care special- secretions or waste products ist, since nails can be thick and the underlying tissue \u2022\t Exposure to communicable diseases is easily injured, which can lead to infection. Special \u2022\t Lack of adequate hygiene facilities or assistance in the heavy-duty equipment may be needed to accomplish proper nail care. Use of safety glasses is recommended home during nail care to prevent eye injuries resulting from flying nail particles. \u2022\t Does the person complain of itching? \u2022\t Is there any evidence of scratching? If proper care is neglected, uncut nails confined in \u2022\t Are there any signs of scabies (fine, wavy, dark shoes often begin to curl under the toes, resulting in a condition called ram\u2019s horn nails. In this condition, the lines, or spots at the webs of the fingers or folds of nail curls over the top of the toe and grows into the the skin)? flesh on the bottom, causing pain. When the discom- \u2022\t Are there any rashes? If so, where are they located? fort becomes severe, the older person may stop wearing What is their appearance (e.g., macular, papular, or shoes and decrease ambulation in an attempt to reduce vesicular)? the discomfort. In such severe cases, care from a podia- \u2022\t Is there any sign of pallor or erythema over bony trist is needed. Nail fungus is increasingly common prominences? with aging. Fungi cause the nails to become thick, \u2022\t Are there any breaks in the skin integrity? If so, brittle, misshapen, and discolored. Fungal infections where? What do they look like? are more likely to affect the feet because the environ- \u2022\t Are any abrasions or skin tears evident? ment in shoes (dark, moist, and warm) supports \u2022\t Is there any change in the amount, distribution, or growth of these microorganisms. Fungal infections are appearance of the hair? more common in older adults with diabetes or other \u2022\t What is the appearance of the toenails? Are they conditions of diminished peripheral circulation. These thickened? Difficult to cut? Discolored? infections need to be recognized and treated so that \u2022\t Are any lesions evident on the feet or ankles? they do not cause more widespread problems. \u2022\t What is the person\u2019s nutritional status? Is the person overweight or underweight? Other Common Foot Problems \u2022\t Is the person alert and able to move freely? If not, Other common foot problems include corns, calluses, what is the level of immobility? blisters, and bunions, which usually result from years \u2022\t Is the person incontinent of bladder or bowel? of wearing poorly fitted footwear, including high \u2022\t Are there pedal pulses? Are they easy or difficult to heels. These conditions often cause discomfort for palpate? older adults and lead to some degree of activity restric- Box 17-1 lists risk factors for skin, hair, or nail altera- tion. Many independent older adults use commercially tions in older adults. available foot remedies or attempt to remove corns or calluses with a knife or scissors. This practice is dan- NURSING DIAGNOSES gerous and significantly increases the risk for serious foot infections, which may necessitate amputation of a \u2002 toe, toes, or the entire foot. Older people with diabetes or impaired peripheral circulation are particularly Risk for impaired skin integrity prone to develop foot ulcers or infections and are at Impaired skin integrity greatest risk for amputation. Risk for impaired tissue integrity Impaired tissue integrity NURSING PROCESS FOR IMPAIRED NURSING GOALS\/OUTCOMES IDENTIFICATION \u2002 \u2002 SKIN INTEGRITY The nursing goals for older individuals with or at risk ASSESSMENT\/DATA COLLECTION for impaired skin or tissue integrity are to (1) remain free from excessive skin dryness or skin breakdown; \u2002 (2) display timely healing of wounds, lesions, and ulcerations; and (3) maintain optimal nutritional status \u2022\t What is the general appearance of the person\u2019s skin? to promote tissue integrity and healing. \u2022\t Are any lesions evident on the scalp? \u2022\t What is the skin color? Are there any signs of pallor, NURSING INTERVENTIONS\/IMPLEMENTATION jaundice, cyanosis, or erythema? If so, where? \u2002 \u2022\t Are there any areas of dry skin? If so, where? The following nursing interventions should take place in hospitals or extended-care facilities:","Care of Aging Skin and Mucous Membranes\u2003 CHAPTER 17\t 277 1.\t Assess the level of impairment and the contribut- Box 17-2\u2003 Products That Help Moisturize the Skin ing factors. Perform a daily skin inspection; measure the location, size, and depth of the affected area or All of these products are available without a prescription. areas; and identify any conditions or changes that Other moisturizers are also available in stores. Ask the may have caused the problem. Changes in skin con- doctor or pharmacist whether these moisturizers would dition can occur rapidly in older adults. Measure work well. and document all areas of concern so that improve- ment or further breakdown can be evaluated. CREAMS AND LOTIONS Explore any possible causes for the problem and \u2022\t Aveeno Daily Moist Lotion institute nursing measures to prevent or reduce \u2022\t Aveeno Intense Relief Hand Creme further tissue damage. \u2022\t Eucerin smoothing repair dry skin lotion \u2022\t Kiss My Face Foot Cream 2.\t Institute measures to reduce the risk for skin and \u2022\t Moisturel therapeutic lotion tissue breakdown. \u2022\t Planet Botanicals Ugandan Shea Butter Hand Cream \u2022\t Reduce the frequency of complete bathing. The type \u2022\t St. Ives Intensive Healing Hand Cream, Fragrance Free and frequency of baths or showers depend greatly on the individual. The condition of the OINTMENTS skin and the presence of perspiration or other \u2022\t Africare 100% Glycerine body wastes must be considered. Some individu- \u2022\t Aquaphor natural healing ointment als require a complete bath or shower daily; \u2022\t Burt\u2019s Bees Miracle Salve others benefit more from a complete bath on a \u2022\t Crisco vegetable shortening biweekly or weekly basis. On days when total \u2022\t Vaseline pure petroleum jelly baths are not taken, partial or sponge baths of the \u2022\t Walgreen\u2019s Advanced Therapy Dry Skin Treatment face, axilla, and perineum provide adequate cleanliness and prevent body odors. Ointment \u2022\t Keep skin free from wastes and exudate by using mild nondetergent soaps. Reducing the frequency of listing over 73,000 commonly used products. EWG ranks bathing is suggested if dryness is a problem. these products, based on scientific data, assigning them a Use of mild, nondetergent, nonperfumed, hazard score of low (0 to 2), moderate (3 to 6), and high (7 to superfatted soaps (e.g., Basis Sensitive Skin, 10). [Author\u2019s note: I became extremely interested in this topic Neutrogena Transparent [fragrance free]) for after having too many friends diagnosed with cancer, and a cleansing decreases excessive skin dryness. cancer scare of my own. After going on the SkinDeep website, \u2022\t Use emollients, lotions, creams, and oils to maintain I was shocked at the scores of some of my favorite products skin moisture. Emollients help keep moisture in and makeup. Because of this, only products with a hazard the skin and reduce dryness. This can reduce the score of \u201clow\u201d are included in this chapter.] Check your own risk of skin tears. Since most preparations are products and learn more at: http:\/\/www.ewg.org\/skindeep effective for only a short period of time, apply them frequently. A variety of preparations are \u2022\t Rinse skin carefully. Soaps tend to dry the skin and available at a wide range of costs. Ointments, should be rinsed off completely before drying. If particularly those containing petrolatum, are a basin is being used, complete rinsing may occlusive and tend to be more long-lasting than require frequent water changes. lotions or creams. Avoid lotions containing alcohol because they can contribute to drying. It \u2022\t Dry skin tissue gently and thoroughly. To decrease may be necessary to try various emollients and skin irritation, dry the skin by patting rather than lotions to find the one (or the combination) that rubbing. If the skin is severely irritated, use soft provides the most relief to the older individual towels that have been rinsed carefully to remove (Box 17-2). all detergents. Safety Alert \u2022\t Turn and position the person frequently, and reduce sources of pressure by keeping bed linen tight and clear \u2002 of foreign objects. Pressure over bony prominences restricts blood flow to the tissues that are being This Lotion May be Hazardous to Your Health! compressed (Figure 17-8). These areas are most likely to become ischemic or necrotic. Redistrib\u00ad Many untested chemicals are allowed into our personal care uting pressure is an important component of products. A common misconception is that if a product is pressure ulcer prevention. Frequent position available for U.S. sale, it must be safe but, in fact, companies changes allow reestablishment of blood flow and are allowed to use any ingredient or raw material without gov- reduce the risk for skin breakdown. The maximum ernment review or approval, except for a very few prohibited time a person should be in one position must not substances and colors. For example, over 1000 additives in exceed 2 hours. More frequent turning is neces- sunscreens are banned from use in the European Union; only sary for individuals at high risk for skin prob- about 10 are prohibited in the United States. SkinDeep is a lems. Base the frequency of position changes database maintained by Environmental Working Group (EWG) on your assessment of pressure points after the","278\t UNIT IV\u2003 Physical Care of Older Adults skin and must be cleansed promptly with gentle person is turned. A 30-degree lateral position washing and rinsing. Apply barrier ointments to (Figure 17-9) is preferred to a full lateral position. clean skin to reduce contact with body wastes. A turning schedule will help ensure that reposi- Check people who are known to be incontinent tioning is done at appropriate times. Pressure of stool or urine frequently to reduce the chance points over bony prominences are most suscep- of prolonged exposure to moisture and body tible to breakdown, but anything that exerts wastes. Special absorbent pads or garments that resistance against the skin can become a pressure wick moisture away from the skin may be appro- point. Foreign objects such as large wrinkles, per- priate. Problems of incontinence are addressed sonal belongings (rosary or prayer beads), or in greater depth in Chapter 18. Once the skin is needle caps trapped under the body can also thoroughly washed and dried, moisture barriers contribute to skin breakdown. Each time the (e.g., Vaseline) can be applied to protect the skin. person is repositioned, inspect the skin for signs These types of preparations must be removed of circulatory reduction such as blanching or from the skin at regular intervals to prevent bac- hyperemia. If these signs are present, establish a terial overgrowth. more frequent turning schedule. Treat reddened \u2022\t Keep the skin dry after episodes of diaphoresis; check areas with caution and do not massage them skin surfaces where moisture caused by normal per- because massage can increase the risk for ulcer spiration can become trapped. Moisture on the formation. skin surface can cause maceration (whitening and softening) and tissue breakdown. Moisture \u2022\t Wash the skin and supply clean, dry linens after epi- caused by perspiration usually evaporates and sodes of incontinence. Urine and stool contain causes few problems unless perspiration is exces- waste products that are highly irritating to the sive or is trapped between skin surfaces (e.g., under pendulous breasts). Frequent sponging FIGURE 17-8\u2003 A Stage IV pressure ulcer in the sacral area of an with clear water and thorough drying, exposure 85-year-old man. Note the sacrum (white area) and necrotic to air, or use of a drying substance such as corn- surrounding muscles. (From Swartz MH: Textbook of physical starch helps reduce the amount of moisture and diagnosis: History and examination, ed 5, 2006, Philadelphia: friction between skin surfaces. Elsevier.) \u2022\t Move and transfer the person carefully. The skin of older individuals is thinner, less elastic, and has less subcutaneous padding than that of younger people. This makes it particularly vulnerable to shearing forces during movement. When the head of the bed is elevated, it is recommended that the elevation be kept at or below 30 degrees to reduce the shearing force that may occur when a person slides down in bed. To reduce the shear- ing forces that occur when tissue is dragged over bed linens, use transfer sheets or other assistive devices when turning, repositioning, or transfer- ring a frail older person. FIGURE 17-9\u2003 A 30-degree lateral position is 30 degrees best to avoid pressure points. (Adapted from Bryant RA, Nix DP, editors: Acute and chronic wounds: Current management concepts, ed 4, 2012, St. Louis: Mosby.)","Care of Aging Skin and Mucous Membranes\u2003 CHAPTER 17\t 279 Table 17-5\u2003 Mattress Surface Types CATEGORIES MECHANISM OF ACTION INDICATIONS EXAMPLES OF MANUFACTURERS\/ PRODUCT NAMES Low-Air-Loss System Prevention of skin breakdown in Hill-Rom\/Flexicair Eclipse Available in Pressure redistribution device patients who cannot Kinetic Concepts, Inc.\/First a full bed Bed: The entire surface is a powered, inflated be turned or have or as an existing skin Step Select overlay surface with air loss breakdown Crown Therapeutics\/SelectAir Overlay: Powered surface, constant inflation Pressure redistribution Mattress and air loss at the surface; place over the for high-risk patients bed mattress Bio Clinic\/Bio Guard High-risk patients BG Industries\/MaxiFloat Foam For patients with burns Crown Therapeutics\/RoHo Available as Redistributes pressure and the cover (top) can or multiple stage III or mattress an overlay reduce friction and shear IV pressure ulcers, or in a full protection of new Gaymar Industries\/Sof-Care mattress Overlay: Placed on top of bed mattress grafts and flaps Full mattress: Used in place of the usual Kinetic Concepts, Inc.\/FluidAir Patients who are at risk Hill-Rom\/Clinitron mattress for or have developed atelectasis and\/or Hill-Rom\/Total Care Sport Static Air-Filled Overlay pneumonia Kinetic Concepts, Inc.\/\t Available as Interconnected air-filled cells, inflated to TriaDyne II an overlay appropriate level Pressure redistribution Air-Fluidized Bed Available as Bed frame with silicone-coated beads that a bed become fluidized when air is pumped through the beads Pressure redistribution, antishear, antifriction surface Kinetic Therapy Available as Provides continuous passive motion to a bed promote mobilization of respiratory secretions; also provides low-air-loss therapy From Potter PA, Perry AG, Stockert PA, Hall A: Basic nursing: Essentials for practice, ed 7, 2011, St. Louis: Mosby. \u2022\t Provide appropriate pads, cushions, mattresses, or calories with emphasis on protein and vitamin C beds that are designed to reduce pressure. Many is particularly important because these nutrients types of beds and mattresses that are designed to are necessary for tissue repair. distribute weight over a larger area and reduce \u2022\t Encourage adequate rest. Tissue healing uses pressure on body tissues are available. The energy and places additional physiologic stress advantages and disadvantages of some of these on the aging body. Therefore, older adults are presented in Table 17-5. Wheelchair pads may require additional rest periods during made of gel or inflated with air help reduce pres- the day. sure on the ischial tuberosities. Only full chair \u2022\t Check wounds daily for signs of inflammation or cushions should be used. Inflatable \u201cdonuts\u201d are infection, and obtain cultures of wound drainage if not recommended because, although they reduce appropriate. The typical signs of inflammation or pressure on one area, they increase pressure on infection may be absent or diminished in older surrounding tissues. This can lead to more isch- adults; therefore, pay special attention to any emia and result in extending the area of tissue open areas. Wound cultures are indicated if any damage. purulent or foul-smelling drainage is observed. Infection delays healing and places additional \u2022\t Encourage older adults at high risk for skin tears to stress on older adults. wear long sleeves, long trousers, or knee high socks. \u2022\t Avoid using adhesive strips for skin tears. If possible, Shin guards and leg protectors have also been hold the dressing in place with a stocking-like or found to help those who experience repeat tears tubular bandage, but be careful it is not exces- on their shins. sively tight. \u2022\t Follow aseptic technique when cleansing wounds, 3.\t Institute measures to promote tissue healing. changing dressings, or applying medications. When \u2022\t Promote adequate nutritional intake. Tissue regen- treatments are ordered for skin breakdown such eration occurs more slowly in older adults than in younger individuals. Increased intake of","280\t UNIT IV\u2003 Physical Care of Older Adults the sharp edges off. The toenails of people with as pressure ulcers, it is essential to use aseptic diabetes and other older adults with circulatory (sterile) technique to prevent the introduction problems should be cared for by a foot specialist. of pathogenic microorganisms into the area. Use emollients if the skin on the feet is very dry. Thorough handwashing between patient con- When emollients are used on the feet, teach older tacts and strict adherence to body substance pre- adults to be aware of the importance of wearing cautions are essential. All older adults should socks to prevent slipping. Encourage a daily change have their own supply of dressing materials that into clean socks or stockings, because clean foot- are kept apart from others\u2019 supplies. Do not take wear reduces the risk for infection. Encourage older multipatient treatment carts to the bedside. persons with diabetes or circulatory impairment of Protect all supplies used for wound care from the lower extremities to wear clean white cotton environmental contamination by dust, water, or socks to promote cleanliness and provide early other such substances. Cleanse dead tissue from recognition of injury or drainage. Use caution to a wound by rinsing or irrigating with normal ensure that the socks fit properly and do not cause saline. Avoid harsh cleansers, povidone-iodine, excessive constriction around the ankles or calves. and hydrogen peroxide because they can damage Document and report promptly signs of foot irrita- underlying healthy tissues. Also, avoid using tion, color change, skin breakdown, or changes in excessive force during irrigation, as this can the appearance of the nails. cause tissue damage. Clean rather than sterile The following interventions should take place in the dressings are used in most situations, as long home: as they comply with the institutional infection- 1.\t Encourage adequate fluid intake and good nutri- control guidelines. A variety of preparations are tion. Nutritious foods and adequate fluid intake are available for wound care; the particular type needed to maintain healthy tissue. Inadequate selected by the primary care provider or wound intake of nutrients such as protein, vitamin A, and care specialist depends on the location and vitamin C can result in fragile tissue that is more stage of the lesion (Table 17-6). Individuals with susceptible to bruising, shearing force injuries, and compromised immune systems may require breakdown. When inadequate intake is suspected, use of sterile technique and supplies. If a patient a more complete assessment (including a food and has more than one lesion, clean the most con- fluid diary) is appropriate. This helps nurses deter- taminated wound (e.g., one near the perineum) mine the cause or causes (e.g., depression and last. Keep dressings clean to prevent cross- illness) and plan suitable interventions. contamination among lesions. 2.\t Maintain adequate humidity in the environment. Exposure to hot, dry air, whether in the desert or in 4.\t Provide good foot care. The feet of older adults are overly warm living quarters, results in excessively particularly susceptible to problems. Poor circula- dry skin. An excessively dry environment intensi- tion, increased incidence of problems such as fies the tendency toward dryness, which is already bunions, excessively thick toenails, and the result of a problem in older adults. The result is skin that is years of wearing poorly fitted shoes all contribute rough, dry, cracked, irritated, and more susceptible to foot problems in older adults. The feet should be to breakdown and infection. Dry mucous mem- soaked regularly to remove old, dry skin. After a branes usually accompany dry skin, increasing the good soaking, dry the feet by patting rather than risk for epistaxis (nosebleeds). Living spaces should rough rubbing. Thoroughly dry the feet, paying be maintained at a temperature of approximately careful attention to the areas between the toes. If permitted, cut the toenails straight across and file Table 17-6\u2003 Dressings by Ulcer Stage PRESSURE PRESSURE DRESSING COMMENTS* EXPECTED CHANGE ADJUVANTS ULCER ULCER None Allows visual assessment STAGE STATUS Resolves slowly Turning schedule Protects from shear without epidermal Support hydration I Intact Not to be used in presence loss over 7-14 Nutritional support days of excessive moisture Transparent Does not always allow Pressure-redistribution dressing surface or chair visual assessment cushion Hydrocolloid","Care of Aging Skin and Mucous Membranes\u2003 CHAPTER 17\t 281 Table 17-6\u2003 Dressings by Ulcer Stage\u2014cont\u2019d PRESSURE PRESSURE DRESSING COMMENTS* EXPECTED CHANGE ADJUVANTS ULCER ULCER Composite film Limits shear Turning schedule STAGE STATUS Heals through reepithelialization Support hydration II Clean Nutritional support Manage incontinence Hydrocolloid Change when seal of Hydrogel dressing breaks; maximal See previous stages; wear time 7 days evaluate pressure- redistribution needs Provides a moist environment Surgical consultation often necessary for III Clean Hydrocolloid Must change when seal of Heals through closure (see stages I, II, and III) dressing breaks; maximal granulation and See previous \t wear time 7 days reepithelialization stages; surgical consultation Hydrogel Applied over wound to sometimes considered for covered with protect and absorb debridement foam dressing moisture Calcium alginate Used with significant exudate; must cover with secondary dressing Gauze Used with normal saline or other prescribed solution; must unfold to make contact with wound Growth factors Used with gauze per manufacturer instructions IV Clean Hydrogel Applied over wound to Heals through covered with protect and absorb granulation and foam dressing moisture reepithelialization Unstageable: Calcium alginate Used with significant Eschar lifts at wound Gauze exudate; must cover with edges as covered secondary dressing debridement with Growth factors progresses eschar Adherent film Used with normal saline or other prescribed solution; must unfold to make contact with wound; fill all dead space with gauze Used with gauze Facilitates softening of eschar Gauze plus Delivers solution and wick Eschar softens ordered wound drainage and Eschar softens solution softens eschar Enzymes Facilitate debridement None If eschar is dry and intact, no dressing used, allowing eschar to act as physiological cover; may be indicated for treatment of heel eschar *As with all occlusive dressings, wound should not be clinically infected. Potter PA, Perry AG, Stockert PA, Hall AM: Fundamentals of nursing, ed 8, 2013, St. Louis: Mosby.","282\t UNIT IV\u2003 Physical Care of Older Adults AGE-RELATED CHANGES IN ORAL MUCOUS MEMBRANES 70\u00b0 F to 72\u00b0 F. Relative humidity between 40% and 60% is most comfortable and beneficial for the Problems in the oral cavity may render an older adult skin and mucous membranes. Commercial humidi- unable to chew certain foods. Inspection of the oral fiers or even open pans of water set around the cavity is an important part of the head-to-toe assess- house help increase the amount of moisture in ment and is needed to determine the status of the the room. individual\u2019s teeth, tongue, and oral mucous mem- 3.\t Avoid excessive exposure to the sun. Older adults branes. Changes in the condition of the gums and oral have fewer melanocytes, which are unevenly dis- mucous membranes may be related to several factors. tributed over exposed body areas. Excessive expo- sure to sunlight can cause irregular, blotchy, and Dental care was not readily available to many of cosmetically unacceptable tanning. Use of a safe today\u2019s older adults during their youth because of the sunblock is recommended when sun exposure is cost and the associated discomfort. Therefore, older expected. Encourage older adults to wear loose, individuals who neglected their teeth now suffer tooth lightweight, light-colored clothing and wide- loss. Even those who maintained good dental practices brimmed hats to prevent exposure to the ultra\u00ad are likely to experience tooth decay and loss because violet rays in sunlight that increase the risk for preventive dental techniques were not as advanced as skin cancer. today. Water fluoridation, which started in the 1940s, has helped prevent some dental problems, resulting in Safety Alert a larger percentage of today\u2019s older adult population who have retained at least some of their teeth. Studies \u2002 show, however, that poor oral hygiene is a major problem for the older population. Reasons for this Sunscreens can be Dangerous Too! include (1) failure of older adults to see dental care as a priority; (2) the cost of dental care; (3) restricted Many sunscreens contain harmful chemicals. For example, access caused by transportation problems or inade- vitamin A, useful in many nighttime creams, can cause skin quate availability of dental services, which is particu- damage and potentially skin cancer when exposed to sunlight larly a problem in rural areas; and (4) physical or (Environmental Working Group [EWG], 2014b). Higher SPF cognitive limitations. Many older adults are unable or formulas contain higher concentrations of the chemicals. The unwilling to maintain good oral hygiene practices. safety rating of various sunscreens by EWG is surprising; Unfortunately, nursing staff members too often place however, not all high SPF formulations are high risk, and a oral hygiene at a lower priority than other more visible surprising number of pink bottled \u201cbaby\u201d sunscreens rank ter- aspects of care. In recent years, oral hygiene has been ribly. The following are some sun safety tips: proven to be a high priority; however, cases of pneu- \u2022\t The best sunscreens are protective clothing, shade, monia have been linked to inadequate oral care in intensive care unit (ICU) patients (Parsons, 2013). avoidance of midday sun (highest radiation), and long Some nursing experts tell others that if you are able to periods of sun exposure. perform only one assessment to determine a person\u2019s \u2022\t Avoid getting sunburned: each sunburn increases your risk overall quality of care, inspect the person\u2019s oral cavity. for skin cancer. When oral care is good, then there is a high probability \u2022\t Wear sunglasses to avoid cataracts. that all of the care is good. Nurses need to recognize \u2022\t Don\u2019t fall for a high SPF rating. SPF 15 to 50+ is the the importance of this aspect of care and give it the safest zone for sunscreens. attention it deserves. \u2022\t Avoid sunscreens and lip balms with vitamin A (also called retinol palmitate or retinol). Did You Know? \u2022\t Avoid sunscreens with oxybenzone (a synthetic estrogen and potential hormone disruptor). \u2002 \u2022\t No insect repellant\/sunscreen combination products. If you need insect repellant, apply it first. Oral Hygiene Care Plan \u2022\t Use cream, not spray: spray contains tiny particles that Development of an oral hygiene care plan (OHCP) has been are potentially unsafe to breathe in. Choose a safer recommended by experts as the best framework for preventive sunscreen (according to the SkinDeep website); reapply oral care in dependent older adults. The OHCP should include often. the frequency of oral care, product recommendations, and specific challenges encountered during oral care. For the first Data from Environmental Working Group (2014). Make sunscreen part of your month, this OHCP should be completed weekly, followed by outdoor working gear. www.ewg.org\/2014sunscreen\/top-sun-safety-tips\/ once every three months (Johnson, 2012). 4.\t Obtain regular professional foot care. Older DENTAL CARIES people, particularly those living alone, often find Tooth decay, loose teeth, and lost teeth are ongoing that foot care is difficult because of the loss of problems in the older adult population. Poor nutrition flexibility. Regular appointments with a foot-care specialist reduce the risk for trauma or infection. Professional foot care is essential for individuals with diabetes or impaired peripheral circulation. 5.\t Use any appropriate interventions that are used in the institutional setting."]