Handouts Finals

Cognition and Perception

Ø Perception The conscious recognition and interpretation of sensory

stimuli that serve as a basis for understanding, learning, and knowing
or for motivating a particular action or reaction.

Ø Cognitive Pertaining to the mental processes of comprehension,

judgment, memory, and reasoning, as contrasted with emotional
processes.

Common visual changes

1. Farsightedness-caused by a loss of elasticity of the lens and

resulting decrease in the power of accommodation.

2. Presbyopia- decreased ability to respond to changes in light,

resulting in night blindness

3. Cataract – cloudy area in the lens of the eye that leads to a

decrease in vision of the eye. It develops slowly which can affect one or
both eyes. Symptoms : faded colors, blurry or double vision, halos around
light, trouble with bright lights and difficulty seeing at night.

Common Auditory Changes

1. Presbycusis- loss of hearing acuity, particularly of higher-pitched

sounds.

2. Otosclerosis- loss of hearing resulting from decreased sound

transmission.

3. Tinnitus- ringing of the ears caused by Meniere disease, age-related

changes or medications.

Meniere’s Disease- a disease of the inner ear that is characterized by

potentially severe and incapacitating episodes of vertigo, tinnitus, hearing
loss and a feeling of fullness in the ear.

Cognitive and intelligence

• Fluid intelligence is the ability to perform tasks or make judgments

based on unfamiliar stimuli. This is sometimes referred to as the ability
to “think on your feet.”

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 • Crystallized intelligence (often called wisdom) is the ability to
perform tasks and make judgments based on the knowledge and
experience acquired throughout

Risk Factors Related to Cognition and Perception in Older Adults

• Vision problems (total blindness, presbyopia, macular degeneration,

cataracts, hemianopsia, detached retina, diabetes, glaucoma, and
significant refractive errors)

• Hearing problems (presbycusis, otosclerosis, and conductive

sensorineural deafness)
Dementia (including Alzheimer disease)
Disturbed cerebral circulation (stroke, aneurysm, and head injury)

• Drugs that affect the sensorium (alcohol, narcotic analgesics,

tranquilizers, sedatives, and hypnotics) Disturbed neurologic function
resulting in decreased levels of consciousness

• Disturbed metabolic states (hypoglycemia and metabolic alkalosis)

Environments with either inadequate or excessive sensory stimulation

Possible Indicators of Hearing Loss

• Difficulty understanding high-pitched voices

• Trouble following a conversation when more than one person is talking

• Difficulty hearing over the phone

• Difficulty hearing when there is background noise

• Complaints that other people are mumbling

• Increased volume of radio or television

• Straining to hear conversation at a normal volume

Nursing Diagnoses

• Risk for Injury related to altered sensory perception Impaired

Verbal Communication related to disturbance in sensory Input

NURSING GOALS/OUTCOMES IDENTIFICATION

• The nursing goals for older individuals with disturbances in

sensory perception are to (1) remain free from injury; (2)

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 demonstrate improved ability to detect changes in the
environment; (3) interact appropriately with the environment;
and (4) demonstrate the ability to compensate for deficits by
using prosthetic devices and alternative senses.

NURSING INTERVENTIONS/IMPLEMENTATION

The following nursing interventions should take place in hospitals or

extended care facilities:

1. Ensure that all caregivers are aware of the person’s sensory problems.
The patient records should identify and prominently display any vision or
hearing problems. Inform nursing assistants and ancillary personnel about
sensory problems and appropriate methods of communication before
assigning them to provide care for an older individual with sensory deficits.

2. Make appropriate sensory contact before beginning care. If the older

adult is hard of hearing, avoid startling him or her. Approaches should be
made so that the older individual can see the nurse, or the individual
should be touched gently on the hand before more personal contact is
made. If the older adult is visually impaired, speak up and introduce
yourself when entering the room. This lets the person know who is there,
even if he or she cannot see a face clearly.

3. Determine the best methods for communicating with older adults.

Be patient and relaxed when working with older adults . When working
with sensorially altered older persons, keep messages as simple as
possible, use easily understood words, and speak clearly. It may be
necessary to reword a statement if the first attempt is not understood.
Avoid overloading the older adult with information when explaining care
or treatments. When writing messages, make sure that the writing is clear
and large enough to be seen easily.

• Modify the environment to reduce risks. Lighting is important for

older adults. Because it takes the aging eye longer to adjust to bright
light, stairs and other hazardous areas should be designed to prevent
glare.

• Hemianopsia – a condition in which a portion of the visual field is lost.

Arrange the furniture to maximize the person’s ability to see . Place
personal belongings toward the good side, and teach the person to

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 turn his or her head and “sweep” the environment to pick up more
visual cues.

Verify that prostheses such as eyeglasses and hearing aids are

functional.

The following interventions should take place in the home

1. Modify the home environment to compensate for sensory

changes. Modifications in the home will help older adults cope with
sensory changes. Increasing the amount of light is the least expensive
and most beneficial change. Lights should be positioned to avoid glare.
Incandescent bulbs are better than fluorescent bulbs because they do not
have a distracting flicker. Burned out bulbs should be replaced promptly.

2. Assist sensorially impaired people in developing techniques or

acquiring devices that will help compensate for losses.
Hearing-Impaired People. Nurses should explain ways that hearing people
can improve communications by:

1. telling others that they are hard in hearing, 2. focusing on the speaker and
paying attention to what is being said; (3) facing the speaker or asking the
speaker to face them; (4) asking the speaker to speak slowly and clearly but
not to shout; and 5) asking the speaker to repeat when information is not
clear.

Assessment for Delirium:

• A Drug -Any recent change in medications, increase or decrease in

dosage, change from specific brand to a generic. Pay special attention
to sedative-hypnotics (including alcohol), antidepressants, opioids,
antipsychotics, anticholinergics, anticonvulsants, antiparkinsonian
medications, and H2 blocking medications

• Electrolyte Imbalance -Abnormal levels of calcium, sodium, or

magnesium often related to malnutrition or dehydration Lack of Drugs-
Missed medication doses

• Infection- Check for urinary tract infection (UTI), signs of inflammation,

respiratory congestion, etc., remembering that the signs may be subtle
in the older adult

• Reduced Sensory Input- Visual or hearing impairment, failure to use

glasses or hearing aids, social isolation

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 • Intracranial Pressure- Recent head injury, history of stroke, meningitis,
history of seizure

• Urinary Retention and or Fecal Impaction-Recent anesthesia, history of

benign prostatic hyperplasia, recent catheter removal.

• Myocardial Problems- Anginal symptoms, abnormal electrocardiogram

(ECG), recent cardiac surgery

Types of Dementia

1. ALZHEIMERS DISEASE

2. VASCULAR DEMENTIA

3. DEMENTIA WITH LEWY BODIES(DLB)

4. MIXED DEMENTIA

5. PARKINSON DISEASE DEMENTIA

6. FRONTO TEMPORAL DEMENTIA

7. NORMAL PRESSURE HYDROCEPHALUS

8. HUNTINGTONS DISEASE

Alzheimer disease is not a normal part of aging. It is a progressive,

degenerative, irreversible form of dementia.

• The disease was first identified in 1906 by Alois Alzheimer, a German

neurologist.

• Most cases of Alzheimer disease occur in people older than 65 years of

age, but it can occur as early as 30 years of age.

• Alzheimer disease affects both men and women of all religions, races,

and so The first signs of Alzheimer disease are subtle changes in

behavior. The disease affects each individual differently; the type and
severity of symptoms, as well as the order of their appearance, differ
from person to person.

• People suffering from Alzheimer disease lose the ability to think,

remember, understand, and make decisions. Consequently, they are often
unable to perform even the most basic activities of daily living. T

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 The ability to control basic body functions such as elimination is also lost

a People with Alzheimer disease suffer personality changes.

They lose the ability to control moods and emotions, leading to

unpredictable and often inappropriate behavior.

Unusual behaviors include wandering, pacing, hiding things, swearing,

disturbed sleep patterns, and repetitive actions.

• There is no known cure for Alzheimer disease. A variety of medications are

being tested for use with this disease, with varying degrees of success.

Stages of Alzheimer Disease

• PRECLINICAL ALZHEIMER DISEASE

• Measurable biologic changes (biomarkers); specific biomarkers

include brain imaging studies and protein in spinal fluid

• No obvious symptoms of memory loss or confusion

MILD COGNITIVE IMPAIRMENT (MCI) CAUSED BY ALZHEIMER

DISEASE

• Mild changes in memory, reasoning, and visual

• perception

• Noticeable to person affected, friends, and family

• Capability of carrying out everyday activities

• Occurs years to perhaps decades before the next stage

• Dementia Caused by Alzheimer Disease

• Memory Impairment

• Behavioral Symptoms

• Impaired ability to function in Daily Life

• The cause of the disease remains unknown, but genetic, chemical,

viral, and environmental factors are suspected. Family history and the
presence of the apolipoprotein E gene appear to indicate an increased
risk for development of the disease.

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 • Alzheimer disease causes gradual changes such as plaques and
tangles in the nerve cells of the brain that can be detected on autopsy.

Neurologic changes result in a loss of the ability to process

information normally

General approaches for working with confused older adults

• Provide a calm, safe, and structured environment with a limited

number of stimuli.

• • Use a calm, gentle, one-on-one approach.

• Speak normally and informally as though the person is not confused
• Allow plenty of time; avoid hurrying.
• Determine the confused person’s reality; avoid confrontation or
forced reorientation

• Encourage reminiscence using family pictures,

• common activities, or objects.

• Provide familiar clothing and personal items from home
• Redirect attention or use some other form of distraction to reduce
anxiety resulting from disturbing thoughts

• Provide safe, repetitive activities within individual capabilities( e.g.,

winding yarn and folding towels)

• • Provide continuity of care with a limited group of caregivers.

• Develop and maintain daily routines for care and activities
• Avoid sudden changes in routine, room, or caregivers.

Complementary and alternative Therapies

• Music Therapy

• Following are some behavioral responses to music:

• • Improved mood
• Decreased depression
• Muscle relaxation
• Diminished fear and apprehension
• Improved physical movement during therapy

ETHICAL PRINCIPLES IN GERIATRIC NURSING

• Beneficence

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 • Non-maleficence

• Futility of treatment

• Confidentiality

• Autonomy and informed consent

• Physician-Patient relationship

• Truth telling and Justice

Ethical Issues in the care of older adult

• Ethics – fundamental part of geriatric, or the provision of

ethical care. Refers to a framework or guidelines for
determining what is morally good.

• 4 major ethical principles:

• 1. autonomy

• 2. Beneficence

• 3. non-maleficence

• 4. Justice

Autonomy- refers to once right to control one’s destiny, that is to exerts

one’s will.

• -the principles evolves around whether the patient can assess the
situation and make a rational decision independently.

Beneficence- The duty to do good to others, to help them directly, and to

avoid harm.

Nonmaleficence- there is an obligation not to inflict harm on others.

• Example: stopping a medication known to be harmful or

refusing to give a medication to a patient if it has not been
proven to be effective.

Advance Care Planning- involves helping patient to begin to think

about the priorities, beliefs and values and how they want to be
cared for in the face of persistent chronic illness and at the end of
life.

• Topics to be addressed:

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 Ø Cardiopulmonary resuscitation

Ø to be hooked to respirator

Ø Artificial nutrition

Ø blood transfusion

Ø organ or tissue donation or whether they want to be transfer

to an acute-care setting for aggressive intervention.

Ø Funeral or memorial services

Ø Buried or cremated

Advanced Directives (AD)- is a legal document that allows patient

to convey their decisions about the type of care they want to
receive in the event that they are unable to express their wishes.

Ø AD are helpful ways for patients to give directions and simplify

the decision-making process.

Living will- another way to express advance directives. It

specifies care preferences when in terminal state at the end-of-
life.

Ø It also provides means to indicate that the patient that the

patient prefer heroic measures not to be initiated.

Ø Proxy- is an individual authorized to act on the patient's behalf if that

person is unable to communicate and can make medical decisions.

Ø Dual Power of Attorney- designation for proxy previously used to

transfer property.

Ø POLST- Physician Order for Life Sustaining Treatment.

Ø MOLST- Medical Orders for Life Sustaining Treatment.

Ø POLST/MOLST- is intended to facilitate end-of-life medical decision

making and assure patient’s wishes are carried out. It effectively
provides standing orders for an end-of-life actions based on advanced
directives.

Ø POLST/MOLST- particularly critical for patients with serious health

conditions who

Ø Want to avoid receiving any or all life-sustaining device treatment.

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 Ø Reside in a long-term care facility and require long term care service.

Ø Might die within next year.

Considerations of ethics of geriatric care

Ø Ethics and laws are separate but overlapping.

Ø End-of-life Care state law governs.

Ø Many health care facilities have ethics committees

Ø Informed Consent

Ø Patient can express their wishes.

Ø In absence of AD. An individual may act as the Proxy

Ø State Guardianship Law.

Ø End-of-of-life-care- It differs from AD in that the latter address

hypothetical situations whereas the patient is experiencing the
implications of (EOL). Whether being made by the Proxy.

Clinicians' role in end-of-life care

Ø Condition being treated

Ø Nature, character of the proposed treatment or surgical procedure.

Ø Anticipated results.

Ø Recognized possible risks complications, benefits of the treatment or

surgical procedures.

Physician Assisted Suicide- In the state of Oregon it is legalized but

very few terminally ill patients have have requested physician assisted to
facilitate suicide.

Ø Futility- mean any treatment that, within a reasonable degree of

medical certainty, is seen to be without benefit to the patient.

Ø Confidentiality

Ø Justice.

ACTS THAT COULD RESULT IN LEGAL LIABILITY FOR NURSES

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 • NEGLIGENCE- OMISSION OR COMMISSION OF AN ACT THAT DEPARTS
FROM ACCEPTABLE AND REASONABLE STATDARDS, WHICH CAN TAKE
SEVERAL FORMS.

• MALFEASANCE- unlawful or improper act (surgical procedure).

• MISFEASANCE- performing an act improperly ( non-signed consent)

• NONFEASANCE- failure to take proper action (not notifying MD with

changes).

• MALPRACTICE- When a nurse fails to competently perform his or her

medical duties and that failure harms the patients. To abide by the
standards of one’s profession(not checking that a NG tube is in the
stomach before administering a tube feeding).

• CRIMINAL NEGLIGENCE- disregard to protecting the safety of another

person(following a confused patients to have matches).

• RESTRAINTS CHEMICAL AND PHYSICAL

Anything that restricts a patient's movement can be considered a

restraint.

• Alternatives should be used whenever possible- alarmed doors,

wristband alarms, bed alarm pads, beds and chairs close to the floor,
increase staff and supervision.

• When restraint is necessary, a physician’s order must be obtained-

must include the type of restraint, condition of patient, and duration of
use.

• Presumed benefit of restraint should be carefully weighed against the

risk of complications and the insult in patients' dignity.

• Physical restraints-should be used only when the patient is a danger

for himself or others and when all other behavior management have
been exhausted

• Chemical Restraints- is by giving psychoactive pharmacological

agent. It is prescribed with caution only when for the clear benefit of
the patient.

• NO CODE ORDERS

• Terminally ill patients that are going to die and resuscitation attempts
would not be therapeutic.

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 • A physician order must be obtained to clearly state the wishes for no
resuscitation- it is a negligence to withhold CPR without an order

• DNR at bedside is not valid without an official order.

• DO NOT RESSUSCITATE ORDERS

• DNR- are legal binding but must be justified as clients' request or

medically indicated.

• When DNR is made, the supporting documentation must include

client’s current condition, prognosis, summary of decision making and
who was involved

SPIRITUALITY

a positive, harmonious relationship with God or other higher power(the

Divine) helps individuals to feel unified with other people, nature and
environment.

Spirituality differs from religion, which consist of human created structures,

rituals, symbolism, and rules for relating to the Divine-highly spiritual
individuals may not identify within a specific religion

SPIRITUAL NEEDS

• LOVE- people need to feel love regardless of physical or mental

condition- social position, material possessions.

• Meaning and purpose- achieving a sense of integrity-

wholeness is supported by the belief that life experiences-both
good and bad make sense and have served a purpose.

• Hope- something in the future- belief and eternal reward are

possible.

• Dignity- make a sense of value and worth through their

connection with God or other higher power

• Forgiveness- achieving closure to unfinished business

• Gratitude- at a time of many losses, they may be guided by a

review of the positive aspects in their life- an attitude of
thankfulness nourishes the spirit..

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 • Transcendence- connected to a greater power, life beyond
material existence and face difficult circumstance.

• Expression of Faith- practices include prayer, worship,

scripture, rituals, and celebration on specific holy days.

EFFECTS OF MEDICATION USE to the elderly

• Polypharmacy- the high prevalence of drugs consumed by

older people and the complexity of drug dynamics in old age
require geriatric nurses to evaluate the effects of drugs given.

• Altered Pharmacokinetics- Absorption, distribution,

metabolism, and excretion of drugs.

• Absorption- decreased gastric blood flow and motility, slower

metabolism.

• Distribution- dehydration will decrease drug distribution, and

lower dosage levels may be necessary.

Who needs Long Term Care

• Age. The risk generally increases as people get older.

• Gender. Women are at higher risk than men, primarily because

they often live longer.

• Marital status. Single people are more likely than married

people to need care from a paid provider.

• Lifestyle. Poor diet and exercise habits can increase a person's

risk.

• Health and family history. These factors also affect risk.

• Long-term care also includes community services such as

meals, adult day care, and transportation services. These
services may be provided free or for a fee.

• People often need long-term care when they have a serious,

ongoing health condition or disability. The need for long-term
care can arise suddenly, such as after a heart attack or stroke.
Most often, however, it develops gradually, as people get older
and frailer or as an illness or disability gets worse.

Palliative Care

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WHO (1) has defined palliative care as:
“an approach that improves the quality of life of patients and their families
facing the problem associated with life-threatening illness, through the
prevention and relief of suffering by means of early identification and
impeccable assessment and treatment of pain and other problems, physical,
psychosocial and spiritual

Palliative care - is an interdisciplinary medical caregiving approach aimed

at optimizing quality of life and mitigating suffering among people with
serious, complex, and often terminal illnesses.

End-of-life care includes physical, emotional, social, and spiritual

support for patients and their families.

The goal of end-of-life care is to control pain and other symptoms so

the patient can be as comfortable as possible.

End-of-life care may include palliative care, supportive care, and

hospice care.

What does end of life care involve?

1. managing physical symptoms.

2. giving emotional support and spiritual care to the person and

their family and friends.

3. helping with everyday tasks, such as washing or dressing.

4. talking about the person's needs and wishes, including helping

them talk to any family or friends if needed.

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