Republic of the Philippines

CATANDUANES STATE UNIVERSITY

Virac, Catanduanes

College of Health Sciences

Course Code : NCM 114 Semester/SY : 1st Semester
Course Title : Care of the Older Adult with RLE No. of Units : _____________________
Program : BS Nursing Time/Days : 7:00- 4:00
Name of Faculty : Anthony T. Emerenciana,RN,LPT Room : Gogon Sirangan, Virac

CARE OF THE GERONTOLOGICAL CLIENT

I. Physiological Changes of Aging

A. Integumentary system B. Neurological System

1. Loss of pigment in hair and skin 1. Changes in mental status

2. Increased nail thickness and decreased 2. Slowed reflexes
nail growth 3. Loss of Balance
3. Thinning of the epidermis 4. Dizziness and syncope
4. Easy bruising and tearing of the skin 5. Slight tremors
5. Reduction in blood flow to the skin 6. Difficulty with fine motor movement
6. Decreased skin turgor 7. Changes in sleep patterns such as
7. dry, itchy, cracked skin decreased total sleep with earlier risings
8. Loss of elasticity and subcutaneous fat 8. Increased susceptibility to hypothermia and
9. Wrinkling of the skin hyperthermia
10. Inadequate sweating
11. Seborrheic dermatitis and keratosis
formation

C. Muskuloskeletal System D. Cardiopulmonary System

1. Posture and stature changes causing a 1. Energy and endurance diminish

decrease in height 2. Lowered tolerance to exercise
2. Kyphosis of the dorsal spine 3. Decreased stretch and compliance of the chest wall
3. Muscle mass decreases and muscles atrophy 4. Decreased rib mobility and lung tone
4. Joint capsule components deteriorate 5. Decreased strength and function of respiratory
5. Decreased mobility range of motion, flexibility muscles
and stability 6. Decreased depth of respirations and oxygen intake
6. Increased stiffness 7. Decreased ability to cough and expectorate sputum
7. Decrease in physical strength 8. Decreased size and number of alveoli
8. Decrease in muscular coordination 9. Decrease compliance of the heart muscle
9. Change of gait, with shortened step and wider 10. Heart valves becomes thicker and more rigid
base. 11. Decreased efficiency of blood return to the heart and
10. Increased brittleness of the bones decreased cardiac output
11. Decrease in deep tendon reflexes 12. Decreased resting heart rate
13. Increased blood pressure
14. Susceptible to postural hypotension
E. Hematological and Immune Systems F. Gastrointestinal System

1. Hemoglobin and hematocrit levels remain within 1. Decrease appetite, thirst, and oral intake
normal range but average toward the low end of 2. Decrease need for calories
normal 3. Digestive disturbances
2. Lymphocyte counts tend to be low 4. Decreased stomach-emptying time
3. Decrease resistance to infection and disease 5. Increased tendency toward constipation
4. Prone to increased blood clotting 6. Tooth loss
7. Difficulty in chewing and swallowing food
8. Decreased absorption of carbohydrates, proteins,
fats, and vitamins
9. Decrease lean body weight
G. Endocrine System H. Renal System

1. Decrease secretion of hormones with specific changes 1. Decreased kidney size, function, and ability to
related to each hormone function concentrate urine
2. Decreased metabolic rate 2. Decreased glomerular filtration rate
3. Decreased glucose tolerance 3. Decreased capacity of the bladder
4. Resistance to insulin in peripheral tissues 4. Increased residual urine and increased incidence of
infection and incontinence
5. Impaired medication excretion
I. Reproductive System J. Special Senses

1. Decreased testosterone production and decreased size 1. Decreased visual acuity

of testes 2. Decreased accommodation in eyes

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 Republic of the Philippines
CATANDUANES STATE UNIVERSITY
Virac, Catanduanes

2. Changes in the prostate leading to urinary problem 3. Decreased peripheral vision and increase sensitivity to
3. Decreased secretion of hormones with the cessation of glare
menses 4. Increased adjustment time to changes in light
4. Vaginal changes, including decreased muscle tone and 5. Presbyopia and cataract formation
lubrication 6. Possible loss of hearing ability
7. Inability to discern taste of food
8. Decreased smell acuity
9. Changes in touch
10. Decreased pain awareness

II. PSYCHOSOCIAL ASPECTS OF AGING

CONCERNS OF THE OLDER POPULATION

 Adequate income
 Functional limitations from chronic illness or disability
 Ability to maintain independence
 Becoming a burden to loved ones
 Isolation
 Dependence on governmental and social systems
 Access to social support systems

A. Adjustment to retirement and loss of income

B. Changes in role function
C. Coping with change and new life situations
D. Changes in social life
E. Diminished quantity and quality of relationships
F. Coping with loss
G. Adjustment to potential deterioration in physical and mental health and well-being
H. Threat to independent functioning
I. Loss of skills and competencies developed early in life

III. ELDER ABUSE AND NEGLECT

A. Description:

1. Involves physical, psychological financial and social abuse

2. Can involve a violation of the client’s rights
3. Individuals at most risk include those who are dependent because of immobility or altered mental status
4. Factors that contribute to abuse and neglect include long standing family violence, caregiver stress, and the
individual’s increasing dependence

B. Types

1. Abuse

a. The willful infliction of pain, injury, or mental anguish

b. Unreasonable confinement or willful deprivation of services, including medical care
c. Can include failure to prevent injury, verbal assaults, the demand to perform demeaning tasks, theft or
mismanagement of personal belongings.

2. Neglect- The lack of provision of services necessary for physical or mental health.

3. Self-neglect

a. The person chooses to avoid medical care or other services that would promote optimal functioning
b. Unless declared legally incompetent, an individual has the right to refuse care

4. Exploitation: Illegal or improper use of an individual’s resources

5. Assessment of Abuse and Neglect

a. Abrasions, lacerations, and bruises

b. Burns
c. Sprains fractures, or dislocations
d. Pressure sores
e. Injuries inconsistent with history
f. Frequent falls
g. Untreated medical problems
h. Inappropriate dress and poor hygiene
i. Excessive drowsiness

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 Republic of the Philippines
CATANDUANES STATE UNIVERSITY
Virac, Catanduanes

j. Overmedication and undermedication

k. Malnutrition
l. Dehydartion
m. Expression of fear in response to touch

6. Implementation

a. Assess for signs of abuse and neglect

b. Report cases of abuse and neglect, as mandated by law
c. Initiate protective services
d. Assess for dysfunctional family systems
e. Promote family functioning and initiate appropriate contact with resources

IV. USE OF RESTRAINTS

A. Physical restraints used to prevent injury are to be avoided, and alternative methods to provide safety must be assessed
prior to the use of physical restraints.
B. A physician’s order must be obtained for the use of restraints
C. Discuss the use of restraints with the client and family
D. Obtain client and family consent for the use of restraints
E. Use the least restrictive device for restraint
F. Use only restraints that have been manufactured as a safety restraint
G. Observe the client frequently, and monitor for alterations in skin integrity and circulation as a result of restraint
H. Restraints need to be removed at frequent intervals (per agency policy) to assess for complications and to allow for
mobility and range of motion
I. Always follow the institutional policy regarding the use of restraints.

V. MEDICATIONS

A. Major problems with prescription medications include adverse effects, medications interactions, medication errors,
noncompliance and the cost
B. Determine the client’s use of over-the-counter medications
C. Keep the use of medications to a minimum
D. Medication dosages are normally prescribed at one third to one half of the normal adult dosages
E. Closely monitor for adverse effects and response to therapy because of the increased risk for medication toxicity
F. Note that a common sign of an adverse reaction in the elderly is an acute change in mental status
G. Assess for medication interactions in client taking multiple medications.
H. Advise the client to use one pharmacy and to notify the consulting physicians of the medications taken
I. Administration of medications
1. Place the client in a sitting position when administering medication
2. Check for mouth dryness because medication may stick and dissolve in the mouth
3. Administer liquid preparations if the client has difficulty swallowing tablets
4. Crush tablets if necessary and give with textured food (nectar) if not contraindicated
5. Do not crush enteric-coated tablets and do not open capsules
6. If administering suppository, do not insert suppository immediately after removing from the refrigerator
7. A suppository may take longer to dissolve because of decrease body core temperature
8. When administering parenteral medication, monitor the site because it may ooze medication or bleed because of
decreased tissue elasticity
9. Do not use an immobile limb for administering parenteral medication
10. Monitor client compliance with taking prescribed medications
11. Monitor for safety in correctly taking medications.

VI. DEMENTIA

A. Description:
1. Organic syndrome with progressive deterioration in intellectual functioning
2. Long and short-term memory loss occurs, with impairment in judgment, abstract thinking, problem-solving ability and
behavior.
3. Results in self-care deficit
4. The most common type of dementia is Alzheimer’s disease

B. Alzheimer’s Disease

1. An irreversible form of senile dementia

2. Individuals with Alzheimer’s disease experience cognitive deterioration and progressive loss of ability to carry out the
activities of daily living.
3. The client experiences a steady decline in physical and mental functioning that frequently requires caregivers to seek
outside resources for assistance

C. Assessment
1. Begins with mild memory impairment
2. The client has difficulty remembering names, appointments, and where things are
3. The client is indifferent and occasionally irritable
4. As the disease progresses, moderate memory impairment, particularly of recent events
5. The client develops a decrease in orientation, is restless, and paces about

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CATANDUANES STATE UNIVERSITY
Virac, Catanduanes

6. As the progression of the disease continues, the client develops severely impaired cognitive function, disorientation,
delusions and agitations
7. Limb rigidity and flexion posture
8. Urinary and fecal incontinence

D. Implementation

1. Identify and reinforce retained skills

2. Assist the client and family members to express feelings about care giving
3. Provide caregiver support and identify the resources and support groups available
4. Provide continuity of care
5. Orient the client to the environment
6. Furnish the environment with familiar possessions
7. Acknowledge the client’s feelings
8. Monitor the activities of daily living
9. Remind the client how to perform self-care activities
10. Maintain independence as much as possible
11. Provide consistent routines
12. Allow plenty of time to complete a task

E. Implementation for specific behaviors

1. Wandering

a. Provide a safe environment

b. Prevent unsafe wandering
c. Provide close supervision
d. Close and secure doors
e. Use identification bracelets if possible

2. Communication

a. Adapt to the communication level of the client

b. Use a calm and reassuring voice
c. Use slow, clear, verbal communications technique
d. Use short words and simple sentences
e. Call the client by name, identify self and wait for a response
f. Ask only one question at a time and give one direction at a time
g. Repeat questions if necessary, but do not rephrase because this may cause confusion in the client
h. Stand directly in front of the client and maintain eye contact
i. Listen and observe the emotion expressed by the client

3. Agitation

a. Assess the precipitant of the agitation

b. Reassure the client
c. Remove items that can be hazardous during the time of agitation
d. Approach the client slowly and calmly from the front; then speak, gesture, and move slowly
e. Use touch gently

4. Altered sleep patterns

a. Allow the client to wander in a safe place until he or she becomes tired
b. Prevent shadows in the room
c. Avoid the use of hypnotics and sedatives because they cause confusion and aggravate the sundown effect.

VII. DEPRESSION

A. Description
1. A functional disorder of mood that is not linked with aging
2. The depression maybe manifested by cognitive impairment or maybe the cause of a decline in mental status
3. Depression can be identified by feelings of sadness, hopelessness and worthlessness and decreased interest in
activities

B. Assessment

1. Difficulty concentrating
2. Feelings of inadequacy and sadness
3. Difficulty sleeping or excessive sleeping
4. Weight gain or loss
5. Vegetative symptoms ( fatigue, change in sleep, appetite and weight, cardiac arrhythmias, change in body temp)
6. Constipation
7. Loss of interest in activities
8. Thoughts of death or suicide

C. Implementation

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CATANDUANES STATE UNIVERSITY
Virac, Catanduanes

1. Assess for signs associated with depression

2. Monitor for the risk of suicide
3. Implement safety precautions for suicide risk
4. Provide and reinforce positive experiences
5. Provide variation in the daily schedule, but limit changes, because change is anxiety producing for older client.
6. Allow the client to talk and reminisce
7. Maintain reality

VIII. PAIN

A. Description:

1. Pain can occur from numerous causes and most often occurs as a result of degenerative changes in the
musculoskeletal system
2. The failure to alleviate pain in the older client can lead to functional limitations affecting the ability to function
independently

B. Assessment

1. Agitation
2. Moaning
3. Crying
4. Restlessness
5. Verbal reporting of pain

C. Implementation

1. Monitor the client for signs of pain

2. Identify the pattern of pain
3. Identify the precipitating factors for the pain
4. Monitor the impact of the pain on activities of daily living
5. Provide pain relief through measures such as distraction, relaxation, massage
6. Administer pain medication as prescribed and instruct the client in their use
7. Evaluate the effects of pain-reducing measures

IX. IMPAIRED VISION AND HEARING

A. Description:

1. Because of the physiological changes that occur with the aging process, clients developed decreased visual and
hearing acuity
2. Such conditions as loss of sight and hearing, cataracts, glaucoma, and presbyopia can develop

X. ALTERED SKIN INTEGRITY

A. Description:

1. Physiological changes include thinning of the epidermis, easy bruising and tearing of the skin and the reduction
in blood flow to the skin
2. Altered skin integrity often occurs in the bedridden or immobile client

XI. IMPAIRED MOBILITY

A. Description:

1. Usually occurs as a result of multiple types of problems and diseases

2. Impaired mobility can occur as a result of decreased physical function related to cardiovascular, pulmonary,
musculoskeletal, or neurological disease or accidents.

B. Assessment

1. Existing disease processes

2. Ambulation ability
3. Ability to care for self

C. Implementation

1. Assess risk of injury

2. Determine cause of mobility restriction
3. Assess mobility restrictions related to disease process
4. Monitor limitations related to all self-care activities
5. Maintain activity through exercise and guided activities
6. Provide rest periods between activities and in the afternoon

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CATANDUANES STATE UNIVERSITY
Virac, Catanduanes

7. Break activities up to last no longer than 20 minutes

8. Perform activities that require a high level of energy in the morning
9. Provide range-of-motions exercises to prevent deformities and contractures.

XII. FRACTURED HIP

A. Description:

1. The most disabling type of fracture for the older adult

2. Usually caused by falls with direct trauma to the hip

XIII. PNEUMONIA

A. Description:

1. The causes of pneumonia in the older client include the effects of the aging process on the respiratory system,
weakness and the inability to cough malnutrition and the use of medications.

B. Assesment

1. Acute change in mental status

2. Confusion
3. Cough
4. Fever
5. Increased respiratory rate
6. Chest pain
7. Dyspnea

C. Implementation

1. Monitor vital signs

2. Assess lung sounds
3. Administer oxygen as prescribed
4. Administer respiratory therapy as prescribed
5. Administer antibiotics as prescribed
6. Provide adequate rest with some progressive activity
7. Mobilize the bed rest client as soon as possible
8. Provide adequate nutrition and hydration
9. Encourage the client to receive immunization against influenza and pneumococcal pneumonia to prevent
infection.

XIV. URINARY INCONTINENCE

A. Description

1. The involuntary release or leakage of urine

2. The physiological changes that occur in the kidney and bladder as a result of the aging process may lead to the
urinary incontinence problems experienced by some older clients.

B. Assessment

1. Contributing factors
2. I and O
3. Urinary incontinence pattern
4. Urinary retention
5. Signs of urinary infection such as burning frequency, foul, odor or confusion
6. Urinalysis results

C. Implementation

1. Monitor I and O
2. Monitor urinary patterns
3. Assess contributing factors such as bladder infection, the distance to the bathroom, difficulty ambulating or
removing clothing, or coughing sneezing, or laughing.
4. Establish a toileting schedule such as every 2 hours or before and after the activity, meals, sleep and rest
periods
5. Provide easy access to bathroom
6. Ensure adequate fluid intake
7. Provide a protection plan for accidents to avoid embarrassment
8. Instruct the client about the use of incontinence aids such as pads.
9. Provide skin care and monitor for skin breakdown
10. Teach Kegel exercises to control stress and urge incontinence,

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CATANDUANES STATE UNIVERSITY
Virac, Catanduanes

KEGEL EXERCISE

1. Contract pubococcygeous muscle

2. Hold contraction for 10 seconds
3. Relax for 10 seconds
4. Work up to 25 repetitions three times a day

Reference:

Saunders, 2nd Edition

Prepared by:

ANTHONY T. EMRENCIANA, RN, LPT

Subject Instructor

Noted:

________________________________
Dean

CSU-F-ACAD-09 Rev. 0 Effectivity Date: June 1, 2015