Nursing Reading Guide - Chapter 19:

Identify the healthcare needs of older adults in terms of chronic illnesses, accidental injuries, and acute care needs (page 433-435):

Chronic Illness: The probability of a person becoming ill increases with age. Chronic health problems or disability also may result from acute illnesses or accidents such as fractures, pneumonia, motor vehicle accidents, and falls. The leading causes of death in older adults are heart disease, cancer and stroke. Although illness affects all dimensions of a person regardless of age, older adults have to contend with a variety of problems as they live with chronic illness. Aging is a normal process, and chronic illness is a pathologic process, but both often occur at the same time. The interrelated changes of aging and the needs imposed by chronic illness increase the risk for problems in all areas of live, including - but not limited to - self care, lifestyle, economics, social factors, and living arrangements. Chronic health conditions can negatively affect an older adult's functioning and quality of life, but many of these can be prevented or modified with behavioral interventions. Implications for Health Care: Consider the following: - Older adults use more health care than any other age group. The health care costs for those older adults with no chronic conditions averaged $5500 yearly but rise to $24500 per year with five or more conditions. - Meeting the expenses of health care is often difficult for older adults and their families. - Medication costs related to chronic illness typically continue for the rest of a person's life, wit multiple medications being the rule rather than the exception. Polypharmacy, the use of many medications at the same time, can pose many hazards for older adults. Complicated regimens need careful review to minimize risks and complications and maximize benefits. Alternative therapies such as herbal remedies have potential to interact with prescribed drugs and cause dangerous effects. Nurses must be able to recognize adverse drug reactions in this population instead of mistaking them for age related changes. - Hospitalization costs continue to rise, and the price of high quality, long term care may well be beyond the patient's/families ability to pay. - Special diets/equipment and medical supplies increase economic difficulties. - Family members must learn how to cope with the needs of the ill person. Included are personal hygiene, medication administration, special diets, elimination, activities of daily living, and recognition of symptoms that necessitate medical attention. - Family members must also adapt to psychological stressors such as changes in communications, changes in roles, and changes in their own lifestyle as they become caregivers. Diversity and Chronic Illness: The prevalence of certain diseases varies among racial and ethnic groups. Poverty, the presence of chronic illnesses, and difficulty accessing the health care system make older adults much more vulnerable to a diminished quality of life caused by disease. Accidental Injuries: The older adult is at an increased risk for accidental injury because of changes in vision and hearing, loss of mass and strength, slower reflexes and reaction time, and decreased sensory ability. Many older adults limit their activities because of fear of a fall that might result in serious health consequences. Falls are the most common cause of injuries and hospital admission in older adults. Approximately 30% to 40% of adults over 65 years living in the community fall at least once a year. Falls may result in a traumatic brain injury (TBI) which accounts for 46%of fatal falls among older adults. Approximately 95% of hip fractures are caused by a fall. Recommendations for prevention of falls in older adults now include an exercise component and vitamin D supplementation. In addition, the combined effects of chronic illness and medications may make an older adult more prone to accidents. Older adults with reduced income may live in inadequate housing in neighborhoods with heavy traffic or high crime rates. They may be isolated from family members and may live alone. Combined with the normal changes of aging and the effects of any illness, older people not only are at increased risk but also have a more difficult time regaining health after an injury.

Describe major physiologic, cognitive, psychosocial, moral and spiritual development and tasks of the older adulthood (pages 425-433, box 19-2):

Physiologic Development: In older adults, all organ systems undergo some degree of decline in overall functioning, and the body becomes less efficient. Box 19-2: Normal Physiologic Changes of Older Adults - General Status: - Progressively decreasing efficiency of physiologic processes results in a fragile balance and hinders the body's ability to maintain homeostasis. - Physical/emotional stressors cause the older adult to be more vulnerable because of decreased physiologic reserves. - The older adult may continue to engage in all activities of middle age but intuitively adjusts to a modified pace and more frequent rest periods. Integument: - Wrinkling and sagging of the skin occur with decreased skin elasticity; dryness and scaling are common. - Balding becomes common in men, and women also experience thinning of hair; hair loses pigmentation. - Skin pigmentation and moles are common, although the skin may become pale because of loss of melanocytes. - Nails typically thicken, becoming brittle/yellowed. - The blood vessels in the dermis become more fragile, causing increased bruising and pupura (hemorrhaging into the skin). Musculoskeletal: - Decreases in subcutaneous tissue and weight commonly are found in the old-old. - Muscle mass/strength decrease. - Bone demineralization occurs; bones become pourous and brittle. Fracture is more common. - Joints tend to stiffen and lose flexibility, and range of motion may decrease. - Overall mobility commonly slows, and posture tends to stoop. Height may decrease 1 to 3 inches. Neurologic: - The central nervous system responds more slowly to multiple stimuli. Hence, the cognitive and behavioral response may be delayed. - Rate of reflex response decreases. - Temperature regulation and pain/pressure perception becomes less efficient. - There may be a loss of sensation in the extremities. - The older adult may experience difficulty with balance, coordination, fine movements, and spatial orientation, resulting in an increased risk for falls. - Sleep at night typically shortens, and the older adult may awaken more easily. Catnaps become common. Special Senses: - Diminished visual acuity (presbyopia) occurs, with increased sensitivity to glare, decreased ability to adjust to darkness, decreased accommodation, decreased depth perception, and decreased color discrimination. Cataracts may further obscure vision. Difficulty reading small print might result. Daytime or night driving might be compromised. - Diminished hearing acuity (presbycusis) occurs, particularly diminished pitch discrimination in the presence of environmental noises. Cerumen buildup is common. As a result of hearing problems, the older adult may withdraw from social events. - The senses of taste and smell are decreased. Sweet and salty tastes diminish first. Sensitivity to odors might be reduced. Problems with nutrition may result. Cardiopulmonary: - Blood vessels become less elastic and often rigid and tortuoius. Venous return becomes less efficient. Fatty plaque deposits continue to occur in the linings of the blood vessels. Lower-extremity edema and cooling may occur, particularly with decreased mobility. Peripheral pulses are not always palpable. Orthostatic hypotension can occur. - The body is less able to increase heart rate and cardiac output with activity. - Pulmonary elasticity and ciliary action decrease, so that clearing of the lungs becomes less efficient. Respiratory rate may increase, accompanied by diminished depth. Gastrointestinal: - Digestive juices continue to diminish, and nutrient absorption decreases. - Malnutrition and anemia become more common. - With reduced muscle tone and decreased peristalsis, constipation and indigestion are common complaints. - Diminished saliva production leads to dry mouth problems. Dentition: - Tooth decay and loss continue for most older adults. - Eating habits may change, particularly if the older adult lacks teeth or has ill fitting dentures. Genitourinary: - Blood flow to the kidneys decreases with diminished cardiac output. - The number of functioning nephron units decreases by 50%; waste products may be filtered and excreted more slowly. - Fluids and electrolytes remain within normal ranges, but the balance is fragile. - B ladder capacity decreases by 50%. Voiding becomes more frequent; two or three times a night is usual. A decrease in bladder and sphincter muscle control may result in stress incontinence or incomplete bladder emptying. - About 75% of men over 65 years of age experience hypertrophy of the prostate gland; surgery may be required if urinary retention occurs. - The older woman's genital tract experiences atrophy, decrease of secretions, and thinning. Cognitive Development: The term cognition indicates cerebral functioning, including the ability to perceive and understand one's world. Cognition does not change appreciably with aging. It is normal for an older adult to take longer to respond and react, however, particularly in new or unfamiliar surroundings; the nurse should allow older patients extra time to ask questions or complete activities. Mild short term (recent) memory loss is common but can be remedied by an older adult using notes, schedules and calendars. Long term memory usually stays intact. Dementia, Alzheimer disease, depression and delirium might occur and cause cognitive impairment. Psychosocial Development: An older adult who has a strong sense of self identity and has successfully met challenges earlier in life will probably continue to do so. This person substitutes new roles for old roles and perhaps continues former roles in a new context. Older adults with a strong self concept typically describe themselves as being healthier than others or "young for their age". A self actualized person has realistic perceptions of self, is a problem solver, is usually spontaneous, needs time to focus on one's own individual potential, and views the world with a sense of appreciation. On the other hand, events that may accompany aging can threaten a person's self concept. Depending on the person's outlook on life and past ability to cope, events such as retirement, loss of health or income, loss of ability to operate a motor vehicle, and isolation can be devastating. The loss of the privilege of driving has serious repercussions for older adults. Aging results in slower reaction times and changes in vision such as increased sensitivity to the glare from approaching headlights as well as alterations in peripheral vision. The state Department of Transportation is an additional resource and may request that an older driver be retested based on identification of a concern from a HCP, police or accident report, or written expressed concern from a family member. Moral and Spiritual Development: Older adults, according to Kohlberg, have completed their moral development. Most are at the conventional level, following society's rules in response to others' expectations. Spiritually, an older adult may remain at an earlier level, often at the individuative-reflective level. Many older adults, however, demonstrate conjunctive faith, integrating faith and truth to see the reality of their own beliefs, or universalizing faith, in which they trust a greater power and believe in the future. Self transcendence is a characteristic of later life that helps one expand beyond personal limits to reach out to others and the environment and a greater awareness of others' beliefs and values. Integration of the past and future in the present facilitates acceptance of where one is in life without regretting past mistakes or fearing the future. As a person ages, spirituality and transcendence are a resource and a source of strength when faced with inevitable changes and loss.

Describe SPICE (page 436):

Recognizing patients at risk for cascade iatrogenesis may help avoid its occurrence. Communication with family members and a systematic approach to assessment is required. The Fulmer SPICES tool has proved effective in identifying common problems experienced in older adults that can lead to negative outcomes. S: Sleep Disorders P: Problems with Eating or Feeding I: Incontinence C: Confusion E: Evidence of Falls S: Skin Breakdown This instrument can be used in all settings and alerts nurses to quickly identify interventions to individualize an older patient's care.

Describe common myths and stereotypes that perpetuate ageism (page 425, table 19-2):

Sometimes, older adults are a victim of ageism. Ageism is a form of prejudice, like racism, in which older adults are stereotyped by characteristics found in only a few members of their group. Fundamental to ageism is the view that older people are different and will remain different; therefore, they don't experience the same desires, needs, and concerns as other adults. Our industrial technological world places a high priority on productivity, and some may thing that retired people have "outlived their usefulness". As well, younger generations often have lost ties to the older generation because of increased mobility of the family; thus many young adults lack experiences with older relatives and their friends. Older people may be incorrectly viewed as being rigid or narrow minded, unable to learn, reliable because of memory loss, too old to enjoy sexual pleasure, or child like and dependent. Many people fear advancing age because of pervasive views that older people are poor, lonely, in frail health, and headed for institutionalization in a long term care facility. These descriptors are not true for most older adults. Most older adults are satisfied with their lives, finding retirement and old age more enjoyable than they had anticipated. 3/4ths live in their own homes, and 1/3 of these live alone. Most older adults maintain close ties with their families and have incomes above poverty levels. Table 19-2: Myths and Realities About Older Adults: -Myth: Old age begins at 65 years of age. - Reality: Defining 65 years of age as "old age" happened arbitarily when 65 years of age was set for Social Security payments in the 1930s, based on the labor market and the economy of that time. -Myth: Most older adults live in long term care facilities. - Reality: Only about 4% of older adults live in long term care facilities. Most older adults own their own homes; 29% live alone, 55% live with spouses, and the rest live with family/friends. - Myth: Most older adults are sick. - Reality: Fully 76% of all older adults rate their health as good or excellent. - Myth: Old age means mental deterioration. - Reality: Although response time may be prolonged from a longer processing time, neither intelligence nor personality normally decreases because of aging. - Myth: Older adults are not interested in sex. - Reality: Although sexual activity may be less frequent, the ability to perform and enjoy sexual activity lasts well into the 90s in healthy older adults. - Myth: Older adults don't care how they look. - Reality: Older adults want to be attractive to others. - Myth: Most older adults are isolated and lonely. - Reality: Loneliness results form death of loved ones or other losses, just as it does with people of all ages. Many older adults are active in social and community activities. - Myth: Bladder problems are a problem of aging. - Reality: Incontinence is not part of aging; it requires medical attention. - Myth: Older adults do not deserve aggressive treatment for serious illnesses. - Reality: Older adults deserve aggressive treatment if they want it.

Summarize theories that describe how and why aging occurs (page 419):

The Genetic Theory of Aging: The genetic theory of aging holds that lifespan depends to a great extend on genetic factors. Genes within the organism control "genetic clocks", which determine the occurrence and rate of metabolic processes, including cell division. According to the wear and tear theory, organisms wear out from increased metabolic functioning, and cells become exhausted form continual energy depletion from adapting to stressors. The Immunity Theory of Aging: The immunity theory of aging focuses on the functions of the immune system. This system - composes primarily of the bone marrow, thymus, spleen and lymph nodes - seeks out and destroys foreign agents (such as viruses, bacteria and perhaps cells undergoing neoplastic changes). The immune response declines steadily after younger adulthood as the thymus loses size and function. Age associated changes in the immune system, also known as 'immunosenescense', are thought to be responsible for the increase in infections such as pneumonia and septicemia, immune disorders, and cancer as adults age. Some authorities believe that nutrition plays an important role in maintaining the immune response; therefore, there is much interest in vitamin supplements (such as vitamin E) that are believed by some to improve immune function. The Cross-Linkage Theory of Aging: Cross-linkage is a chemical reaction that produces damage to the DNA and cell death. As one ages, cross-links accumulate, leading to essential molecules in the cell binding together and interfering with normal cell function. The Free Radical Theory of Aging: Free radicals, formed during cellular metabolism, are molecules with separated high-energy electrons, which can have adverse effects on adjacent molecules. Lipids, found in cell membranes, as well as proteins and cell organelles, are affected. Over time, irreversible damage results from the accumulated effects of this damage.

Identify dementia, depression, and delirium (page 436):

Dementia: dementia refers to various organic disorders that progressively affect cognitive functioning. Dementia is chronic and usually develops gradually. Of the dementias that affect older adults, Alzheimer disease (AD) is the most common degenerative neurologic illness and the most common cause of cognitive impairment. A common problem in patients with dementia is sundowning syndrome, in which an older adult habitually becomes confused, restless, and agitated after dark. Delirium: sometimes delirium and depression in an older adult are mistaken for true dementia. Delirium, a temporary state of confusion, is an acute illness that can last from hours to weeks and resolves with treatment. Drug interactions, circulatory or metabolic problems, nutritional deficiencies, or a worsening illness are likely the real cause. An older adult may also become confused when too many changes or losses occur at one time or when moved to a different environment. Treatment of delirium may include stopping unnecessary medications, as well as interventions to resolve infection and metabolic alterations. Medications that reduce agitation may be prescribed in certain circumstances. The nurse can use reality orientation which involves interventions to redirect the patient's attention to what is real in the environment. Depression: extreme or prolonged sadness in an older adult may be a warning sign of depression. Death of a spouse or friends and changes in living environment and financial resources can precipitate feelings of depression. There is usually a distinct change of behavior accompanied by other specific signs/symptoms of depression, such as sleep disturbances, weight loss, difficulty with concentration, and suicidal thoughts or preoccupation with death. Depression usually does not resolve without treatment and is frequently underdiagnosed. The geriatric Depression Scale (short form), a 15 question screening tool, can be used effectively in older adults in any setting. When combined with a mental health assessment by a professional, it can facilitate a diagnosis of depression. Treatment for depression usually involves psychotherapy or counseling along with antidepressant medication. In any older adult, hoplessness rather than sadness is more often associated with suicidal intent. Alcohol or prescription drug abuse is most often associated with suicides in this age.

Define common health problems of middle adults (page 423):

Middle adults are subject to physical and emotional health problems with lifestyle behaviors, developmental or situational crises, family history, and the environment. Both acute and chronic illnesses are more likely to occur, and recovery takes longer. This is a result of slower and more prolonged responses to stressors, more pronounced reactions to an illness, and the possibility of more than one illness being present at a time. The leading causes of death in the middle adult years are malignant neoplasms; cardiovascular disease; unintentional injury including poisoning, motor vehicle accidents, and falls; diabetes mellitus; chronic lower respiratory disease; and cerebrovascular causes. Other major health problems include rheumatoid arthritis, obesity, alcoholism, and depression. The risk for these common health problems often depends on a combination of lifestyle factors and aging. As one gets older, energy requirements decrease. Middle adults tend to maintain previous eating patterns and caloric intake while being less physically active. This trend can result in obesity and atherosclerosis, with and increased risk for hypertension, coronary artery disease, renal failure, and diabetes. Additionally, smoking and alcohol consumption put the person at greater risk for cancer, chronic respiratory diseases, and liver disease. Chronic illness in middle adults has a major effect on self concept and may precipitate changes in life structure. For example, after a serious heart attack, a man may face changes in his family role, his earning capacity, and his social relationships. Such changes usually cause great stress. Middle age does not automatically result in physical or emotional health problems. Many men and women remain healthy throughout their lives, but knowing preventative health care practices and their special needs at this age can help middle adults have improved quality and quantity of life.

Describe common health problems for the older adults (pages 433-434):

Nursing care for older adults should be based on two principals: - Most older people are not impaired but are functional in the community, thereby benefiting from health oriented interventions. - Older people are more vulnerable to physical, emotional and socioeconomic problems than people in other age groups and may require special attention to health promotion and maintenance. Chronic Illness- The probability of a person becoming ill increases with age. Chronic health problems or disability also may result from acute illnesses or accidents such as fractures, pneumonia, motor vehicle accidents, and falls. The leading causes of death in older adults are heart disease, cancer, and stroke. Although illness affects all dimensions of a person regardless of age, older adults have to contend with a variety of problems as they live with chronic illness. Aging is a normal process, and chronic illness is a pathologic process, but both often occur at the same time. The interrelated changes of aging and the needs imposed by chronic illness increase the risk for problems in all areas of life, including - but not limited to - self care, lifestyle, economics, social factors, and living arrangements. Chronic health conditions can negatively affect an older adult's functioning and quality of life, but many of these can be prevented or modified with behavioral interventions. Accidental Injuries - The older adult is at increased risk for accidental injury because of changes in vision and hearing, loss of mass and strength, slower reflexes and reaction time, and decreased sensory ability. Many older adults limit their activites because of fear of a fall that might result in serious health consequences. Falls are the most common cause of injuries and hospital admission in older adults. Approximately 30% to 40% of adults over 65 years living in the community fall at least once a year. Falls may result in a traumatic brain injury (TBI) which accounts for 46%of fatal falls among older adults. Approximately 95% of hip fractures are caused by a fall. Recommendations for prevention of falls in older adults now include an exercise component and vitamin D supplementation. In addition, the combined effects of chronic illness and medications may make an older adult more prone to accidents. Dementia, Depression, and Delirium - When a serious mental impairment occurs, the effect on the patient and family can be devastating. Dementia refers to various organic disorders that progressively affect cognitive functioning. Dementia is chronic and usually develops gradually. Of the dementias that affect older adults, Alzheimer disease (AD ) is the most common degenerative neurologic illness and the most common causes of cognitive impairment. It is irreversible and progresses from deficits in memory and thinking skills to an eventual inability to perform even the simplest of tasks. Delirium, a temporary state of confusion, is an acute illness that can last from hours to weeks and resolves with treatment. Drug interactions, circulatory or metabolic problems, nutritional deficiencies, or a worsening illness are likely the real cause. An older adult may also become confused when too many changes or losses occur at one time or when moved to a different environment.

Describe major physiologic, cognitive, psychosocial, moral and spiritual developments and tasks of middle adulthood (pages 425 - 433, box 19-2):

The middle adult years are characterized by greater expendable wealth, renewed relationship with one's spouse or partner, and expanded social relationships and family roles. Physiological Development: In the early years of this period of life, physical functions are usually still effective. As time passes, gradual internal and external physiologic changes occur. Some examples are: - Fatty tissue is redistributed; men tend to develop abdominal fat, women thicken through the middle. - Skin is drier. - Wrinkle lines appear on the face. - Gray hair appears, and men may lose hair on the head. - Cardiac output begins to decrease. - Muscle mass, strength and agility gradually decrease. - There is a loss of calcium from bones, especially in perimenopausal women. - Fatigue increases. - Visual acuity diminishes, especially for near vision (presbyopia). - Hearing acuity diminishes, especially for high pitched sounds. - Hormone production decreases, resulting in menopause or andropause. The person must modify self image and self concept to adapt successfully to and to accept these normal changes. Cognitive Development: Cognitive and intellectual abilities of middle adults change little from young adulthood. There is often increased motivation to learn, especially if the knowledge gained can be applied immediately and has personal relevance. Problem solving abilities remain throughout adulthood, although response time may be slightly longer (not due to decreased ability but due to a longer search through more memories and desire to think a problem through). Psychosocial Development: The middle adult years are often a time of increased personal freedom, economic stability, and social relationships. This is also a time of increased responsibility and an awareness of one's own mortality. One realizes that their life may be half or more past and may feel many things are still undone. This realization can lead to a developmental crisis and situational stressors. Several theorists describe developmental tasks as follows: Erikson's Theory - The middle adult is in a period of generativity versus stagnation. The tasks are to establish and guide the next generation, accept middle age changes, adjust to the needs of aging parent, and reevaluate one's goals and accomplishments. Adults who do not achieve these tasks tend to focus on themselves, becoming overly concerned with their own physical and emotional health needs. Havighurst's Theory - The developmental tasks of the middle adult described by Havighurst are learned behaviors arising from maturation, personal motives and values, and civic responsibility. To successfully master this developmental stage, the middle adult must accept and adjust to physical changes, maintain a satisfactory occupation, assist children to become responsible adults, adjust to aging parents and relate to one's spouse or partner as a person. Levinson's Theory - Levinson theorized that the middle adult may choose either to continue an established lifestyle or to reorganize one's life in a period of midlife transition. Gould's Theory - Gould viewed the middle years as the time when adults look inward; accept their lifespan as having definite boundaries, and have a special interest in spouse, friends, and community; and increase their feelings of self satisfaction, value spouse as a companion, and become more concerned with health. Employment: Middle aged adults might experience changes in employment. These changes often result from a need for increased job satisfaction, satisfying a life long goal, or economic conditions. Spousal Relationships: Relationships with one's spouse or partner may change. Although for many this is a time of greater security and stability, with stronger emotional commitment and sharing, for some it is a time of disenchantment. Either partner may develop negative or critical feelings and attitudes as a result of changes in physical appearance, energy levels, or sexual needs/abilities. Relationships with children and aging family members: Middle aged adults may be caught in a "generation sandwich". Their children may be independent and married, with children of their own, or may be recent college grads who have returned home to live. Although much has been written about the "empty nest syndrome" that occurs when the last child leaves the home, most parents welcome the increased space, time and independence they have when active parenting ceases. As their involvement with and responsibility for children decrease, they may have an increased need to help care for aging parents and other family. The physical aging or death of a parent makes one's own aging and inevitable death a reality. Moral Development: According to Kohlberg, a middle adult may either remain at the conventional level or move to the postconvential level of moral development, especially if the individual has had sustained responsibility for the welfare of others and has consistently applied ethical principles developed in adolescence. At this level, the adult believes that the rights of others take precedence and takes steps to support those rights. Spiritual Development: As with moral development, not all adults progress to Fowler's paradoxical - consolidative state of spiritual development. Fowler believed that only some people reach this stage and only after 30 years of age. Most middle adults are less rigid in their beliefs and have increased faith in a supreme being as well as trust in spiritual strength.

Describe nursing interventions to promote health in older adults (page 438-439, table 19-7):

The nurse should teach the patient and family general health promotion activities. This is important because older people often believe themselves "too old" to worry about nutrition, exercise, health screenings, and immunizations. In addition to the recommended screenings, examinations, and immunizations the following should be emphasized: - Eat a diet that includes all food groups; is low in fat, saturated fat, and cholesterol; balances calories with physical activity; has recommended amounts of fruits, vegetables, and grains; and uses sugar and salt in moderation. - Make exercise a part of daily activities. Multiple studies have demonstrated that regular aerobic exercise can reduce the risk for dementia and that resistance training may improve cognition. - Discuss with your primary physician whether to include a vit D supplement as part of your daily routine. Vitamin D is considered moderately beneficial for helping prevent hip fractures and other broken bones in older adults. - Drink alcohol in moderation. - Do NOT smoke An older adult who requires surgery or medical treatment for chronic or acute illness has special, age related needs regardless of the setting for care. Nurses must recognize physiologic and psychosocial interrelationships and view older patients holistically. Illness can severely disrupt an older adult's ability to function independently. The focus of nursing care is to assist older patients to function as independently as possible and to support their individual strengths. Table 19-7: Promoting Health in Older Adults: Area of Concern: Physiological Function Nursing Actions: - Maintain physiologic reserves. Maintain ongoing assessments for early detection of problems. - Review perceptions of current health status, health problems, and prescribed or OTC medications. - Include nursing care that maintains physical status, such as skin care and planned rest and activity. Area of Concern: Cognitive Function Nursing Actions: - Slow pace of activity and wait for responses. - Be sure eyeglasses and hearing aids are used; ensure that lenses are clean and batteries are strong. Area of Concern: Psychosocial Needs Nursing Actions: - Be aware that illness, hospitalization, or changes in living arrangements are major stressors. - Assess and support sources of strength, including cultural and spiritual values and rituals. - Encourage use of support systems; family, friends, community resources, and pets. - Set mutual goals and encourage the patient's role in making decisions about care. - Encourage life review and reminiscence. - Encourage self care. - Consider the patient's background, interests, capabilities, values, culture, and lifestyle when planning care. Area of Concern: Nutrition Nursing Actions: - Assess for lost or damaged teeth; ensure that dentures fit properly. Provide foods appropriate to the patient's ability to chew. - Assess height, weight, eating patterns, and food choices. If weight is being lost, assess income, storage, and transportation. - Assess swallowing ability. - Consider using supplements. Area of Concern: Sleep and Rest Nursing Actions: - Discourage excessive napping. - Assess normal bedtime, time for rising, bedtime rituals, effects of pain, medications, anxiety and depression. Area of Concern: Elimination Nursing Actions: - Assess frequency of bladder elimination as well as problems with incontinence. - Assess normal times for bowel movements, changes in activity, privacy, and medications. - Ensure that the floor is not cluttered, the toilet is easily accessible, lighting is adequate, and privacy is provided. - Suggest having safety bars installed in the bathroom. - Review diet for necessary fluid and fiber content. Area of Concern: Activity and Exercise Nursing Actions: - Assess ability to walk; ensure that assistive devices (walker/cane) are available. - Consider effects of illness, surgery, medications, and changes in diet and fluid intake on strength and motor function. - Ensure an uncluttered environment with good lighting; suggest using a night light and removing throw rugs. - Slow the pace of care, allowing extra time to carry out activities. Area of Concern: Sexuality Nursing Actions: - Assist as necessary with hygiene, hair care, oral care, clean clothing and bedding, makeup and shaving. - Maintain a clean, odor free environment. - Demonstrate genuine caring; ask preferred name, listen carefully, and respect belongings. - Discuss safer sex if appropriate. - Discuss water soluble lubricants with women; refer men for evaluation if erectile dysfunction is a concern. Area of Concern: Meeting Developmental Tasks Nursing Actions: - Promote continued development and maintenance of functional health by identifying unmet tasks, feelings of isolation, and physical or sensory limitations. - Assist in finding creative solutions to developmental tasks. - Collaborate with other health care providers to provide information and referral to community resources for the patient and family.