Gerontology
Gerontology
Gerontology
Dementia
Goals : The client can improve thought processing at least at baseline level.
-Memory changes
-Difficulty in communication
3. Give one simple direction at a time and To prevent confusion of the patient.
repeat it as necessary
4. Begin each interaction with the client by Help the clients to identify his/her
identifying ourselves and encourage the identity and to enhance memory.
family members to call clients by his/her
name.
5. Avoid high expectations more than High expectations may cause clients to
patient capability to do something. become frustrated and angry.
6. Provide a safety environment such as To reduce the risk of falls and injury
raising the side rail for the clients who
have the confusion.
8. Provide opportunities to the clients for Help to prevent isolation and forcing
social interaction without forcing them. interaction that might lead to confusion.
Goals: patient will be able to perform basic activity daily living at minimal aid and assistant
-fully independent
6. Provide assistant if necessary especially to help patient improves their fine and
for activities that required energy and gross motor also balancing themselves
may confuse the patient such as dressing alongside with the assistant
and grooming like button up the shirt
7. Instruct family members to keep patient’s To keep the patient tidy as they are
hair short as appropriate deficient in self-care and to facilitate the
patient to wash it on their own during
bathing to maintain hygiene
8. Give praise to the patient for any ADLs because it will make patients feel
that they did by themselves or even with appreciated and want to do better for
their caregiver such as “Mr. Lee, you did tomorrow
great today.”
Evaluation: patient able to perform basic activity daily living at a minimal aid and assistant
Nursing Diagnosis: Wandering related to instability of mind statue
2. Assess reason for wandering if patient To detect any problems patients have
able to verbalize as an example tell to and cope by giving the right plan. For
visit someone, or just want to wander for example, a patient wants to meet his
enjoy friends. Company and help to avoid any
injury
3. Provide a bed near the counter staff To monitor patient behavior and
nurse full with the safety side rail, lowest minimize the risk of fall or injury when
bed, and lock the bed. Ensure to switch they have the intention to escape or
on the lamp during bedtime wandering
5 Avoid using restraints if at all possible to Restraints might increase the risk of
control patient behavior agitation, depression, and anxiety. It can
lead to complications of immobility and
feeling of powerlessness
6 Apply an identification bracelet or install To identify the patient identity and detect
a chip inside a bracelet for the elderly at the location of a patient
his wrist as the safety and facilitate for
searching if occur the missing or lost
elderly location
7 Identify how the family handles the Helps to determine potential appropriate
patient’s wandering behavior methods of managing patient’s behavior
by using a consistent method
Goal: Patient’s memory will be improved and remember slowly about their life.
1 Assess the overall cognitive memory because MMSE is very useful as a first step
through screening tests such as evaluation for determining whether a patient
mini-mental state examination (MMSE) has cognitive impaired thinking that needs
from the perspective of orientation, to refer to get suitable treatment for the
registered and recall patient.
2 Monitor symptoms that are experienced as baseline data and to plan the next
by patients when forgetfulness such as intervention that is appropriate with the
they cannot remember their name and patient to minimize the level of forgetfulness
always ask the same question over and that occurs among patients.
again.
3 Offer assistive devices or supervision to promote patient safety during ADL and
when patients bathe by using a as protection from an injury that harms the
commode chair, during their cooking patient.
must be monitored by the caregiver,
and feeding patients if they cannot eat
by self.
4 Provide patients with a single instruction because the patient cannot easily
using simple language that they remember multi instructions at one time
understand when the necessary
instructions need to be followed
5 Encourage family members to to stimulate the patient's brain for more
frequently ask about patient’s past function to recall back and decrease the
stories as example sweet memories at level of forgetfulness and patients become
a young age such as marriage, having more remembering.
children, and share about popular
movies in the past like Bujang Lapok
6 Provide the patient with a medicine to prevent patients from forgetting to take
container that has days, encourage medication for their illness and helps to
patient to know the color and shape of minimize patients to forget the important
medicine and always remember patient things
to take medication on time for their
premorbid disease for example
hypertension, diabetes mellitus that
prescribed by a doctor
7 Encourage the family member to always to avoid the patient out of a sudden and
monitor and make sure their door and cannot remember the way back home
gates are always closed especially because they had a problem with impaired
when they are busy with work thinking and it was dangerous to the
patient.
8 Provide some time with patients as to minimize patient forgetting and help their
quality time to recall their memory such brain to more function to remember what
as ask their name, age and avoid from their routine is when they have leisure time.
force patients to remember what these
words that always use and what they
are routine
9 Maintain a nice, quiet, and comfortable to avoid excessive sensory neurons and
neighborhood can increases interferences.
Evaluation: Patient’s memory improved and they remembered about their routine
Nursing diagnosis: Inappropriate behavior related to instability of the mind
state.
Goal: Patient will have appropriate maintenance of mental and psychological function as
long as possible, and reversal of behaviors when possible.
1 Assess the patient’s changes in mood dementia patients always having this
and personality such as feeling happy, difficulty which will make them feel the
disappointed, sadness by using cam burden and can trigger them to act in
score inappropriate ways to express their
emotions
(confusion assessment method)
2 Assess why the patient is behaving in It may be easier to figure out ways to
that way such as they will isolate prevent the behavior from happening
themself from others if they feel again
disappointed, refuse to eat, or attract
more attention from other patients or
staff
3 Approach and talk with the patient by to comforting them and prevent them
using a soft voice and talk gently from acting violently due to restricted
activities
4 Provide patient a conducive, safe, and dementia patient tend to have trouble in
comfortable dim light room with good sleep which when they get not enough
ventilation, and warm milk before going sleep, it will make they have confusion
to sleep and fatigue
5 Introduce patients with each other, to prevent from people feel discomfort
doctor and staff nurse because at this
stage patients tend to get confused with
people’s identity, they sometimes think
of strangers as their family
6 Advice and educate family members to to ensure patients get enough love and
always giving attention and be close don’t feel left out that can cause them to
with patients such as helping patients isolate or experience emotional stress
to manage themself and feeding them and cause them to do things they
shouldn't
7 Assess the patient's ability to cope with Patients may exhibit assertiveness or
events, interests in surroundings and aggressiveness to compensate for
activity, motivation, and changes in feelings of insecurity, or develop more
memory pattern. narrowed interests and have difficulty
accepting lifestyle changes.
Assessment
1.Review history and note traumatic events that may have occurred.
Traumatic events can cause anxiety and lead to isolation from social situations.
3. Assess feelings about self, ability to control the situation, and sense of
hope.
Gauging the level of hopelessness and powerlessness may help the nurse
understand the severity of the situation.
Interventions:
Educate the patient and family about the importance of social interaction and
activity.
● Rationale: Education can help the patient and their family understand the
benefits of social engagement and activity for overall health and well-being.
This knowledge can motivate the patient to participate in activities and reduce
withdrawal.
● Rationale: Allowing the patient to verbalize their feelings can be therapeutic and help
them feel heard and understood. A supportive environment fosters trust and can help
alleviate feelings of isolation and hopelessness.
● Rationale: Setting small, attainable goals can help the patient regain a sense of
purpose and accomplishment. This process can improve self-esteem and provide a
sense of progress and hope.
● Rationale: Engaging in enjoyable activities can enhance the patient's mood and
provide positive reinforcement. Activities that align with the patient’s interests can
help counter feelings of worthlessness by highlighting their abilities and strengths.
● Rationale: Educating the patient about their condition and how to manage it can
empower them and reduce feelings of helplessness. Knowledge can provide a sense
of control and improve their outlook on their ability to cope with the disease.
Facilitate social support and interaction with peers, family, and support groups.
● Rationale: Cognitive-behavioral techniques can help the patient identify and reframe
negative thoughts, reducing feelings of worthlessness and hopelessness. Promoting
positive thinking can improve the patient's overall outlook and mental health.
Assessment:
Interventions:
1. Discuss current options and provide a list of helpful actions to gain a sense
of control over the situation.
These options facilitate the use of own actions, validate reality, and promote a sense
of control of the situation.
Assessment
1. Assess for a suicide plan.
A patient should be directly asked if they want to kill themself and if they have a
specific plan to do so to determine intent.
3. Administer medications.
Medications such as anti-depressants, benzodiazepines, and antipsychotics should
be given in a controlled and monitored setting.
4. Promote safety.
If on an inpatient behavioral health unit, the patient may require 1:1 supervision to
ensure safety. Items that could be used to harm themselves such as clothing items,
cords, and sharp objects should be removed.
5. Continually re-evaluate suicide risk.
Especially after mood changes and at discharge as a patient who is feeling better is
at the highest risk for suicide because they may now have the energy to carry out
their suicide.
● Rationale: A safety plan provides the patient with concrete steps to follow
during a crisis, including whom to contact and where to seek help. This plan
empowers the patient and provides a structured approach to managing
suicidal thoughts.
Engage the patient in activities that promote social interaction and support.
Educate the patient and family about the signs of worsening depression and
suicidal ideation.
● Rationale: Education helps the patient and their family recognize early
warning signs and seek timely intervention. Knowledge of these signs can
facilitate prompt action and potentially prevent a suicide attempt.
● Rationale: Patients with disturbed thought processes may be at risk for injury
due to impaired judgment and confusion. Creating a safe environment
reduces the risk of accidents and enhances the patient's safety.
Use clear, simple communication and provide instructions one step at a time.
● Rationale: Cognitive activities and mental exercises can help stimulate brain
function and improve cognitive abilities. Engaging in these activities may slow
cognitive decline and enhance mental sharpness.
Educate the patient and family about the condition and coping strategies.
● Rationale: Education helps the patient and their family understand the nature
of the cognitive disturbances and how to manage them effectively. Knowledge
of coping strategies can empower them to handle challenges and support the
patient’s well-being.
● Rationale: Physical activity and proper nutrition are important for overall brain
health. Exercise increases blood flow to the brain, and a balanced diet
provides essential nutrients that support cognitive function.
1. Assess and monitor the patient's vital signs regularly, especially blood
pressure and heart rate in different positions (lying, sitting, standing).
○ Rationale: Regular monitoring helps identify changes in blood
pressure and heart rate, which are crucial for detecting orthostatic
hypotension and evaluating the effectiveness of interventions.
2. Educate the patient on how to change positions slowly (e.g., from lying
to sitting, and then to standing).
○ Rationale: Gradual position changes can help prevent sudden drops in
blood pressure, reducing the risk of dizziness, fainting, and falls
associated with orthostatic hypotension.
3. Encourage the patient to stay hydrated and consume adequate fluids.
○ Rationale: Proper hydration can help maintain blood volume and
prevent drops in blood pressure, thereby improving cardiac output and
reducing the risk of orthostatic hypotension.
4. Advise the patient to avoid prolonged bed rest and encourage regular
physical activity as tolerated.
○ Rationale: Regular physical activity can improve cardiovascular health
and enhance blood circulation, which can help mitigate the effects of
orthostatic hypotension and improve overall cardiac output.
5. Educate the patient about wearing compression stockings if
appropriate.
○ Rationale: Compression stockings can help improve venous return
and prevent blood pooling in the lower extremities, thereby reducing
the risk of orthostatic hypotension and enhancing cardiac output.
6. Administer prescribed medications and monitor for side effects.
○ Rationale: Medications may be prescribed to manage blood pressure
and improve cardiac output. Monitoring for side effects ensures patient
safety and the effectiveness of the medication regimen.
7. Teach the patient to avoid large meals and to eat smaller, more frequent
meals.
○ Rationale: Large meals can divert blood flow to the digestive system,
potentially exacerbating orthostatic hypotension. Smaller, more
frequent meals can help maintain more stable blood pressure levels.
8. Advise the patient to avoid alcohol and excessive caffeine consumption.
○ Rationale: Alcohol and excessive caffeine can cause vasodilation and
diuresis, leading to a drop in blood pressure and increasing the risk of
orthostatic hypotension.
9. Collaborate with a dietitian to ensure the patient’s diet supports
cardiovascular health.
○ Rationale: A dietitian can provide specialized dietary
recommendations to help maintain blood pressure and improve cardiac
output, ensuring the patient receives optimal nutritional support.
10. Educate the patient and family about the importance of recognizing and
reporting symptoms of orthostatic hypotension (e.g., dizziness,
lightheadedness, fainting).
○ Rationale: Early recognition and reporting of symptoms can lead to
timely intervention and prevent complications associated with
orthostatic hypotension, such as falls and decreased cardiac output.
11. Encourage the patient to elevate the head of the bed when sleeping.
○ Rationale: Elevating the head of the bed can help reduce the risk of
orthostatic hypotension upon waking by preventing sudden drops in
blood pressure when transitioning from a lying to a standing position.
Risk for fall related to lightheadedness or dizzines upon standing
Educate the patient to change positions slowly and gradually (e.g., from lying
to sitting, then standing).
● Rationale: Gradual position changes can help prevent sudden drops in blood
pressure, reducing the risk of dizziness, lightheadedness, and subsequent
falls.
Ensure the patient uses assistive devices (e.g., canes, walkers) if needed.
Encourage the patient to stay hydrated and maintain adequate fluid intake.
Advise the patient to avoid standing for prolonged periods and to sit down if
feeling lightheaded.
● Rationale: Limiting prolonged standing and sitting down when feeling dizzy
can prevent falls by reducing the risk of sudden drops in blood pressure and
loss of balance.
Teach the patient and family about the importance of a safe home
environment, such as removing tripping hazards and ensuring good lighting.
● Rationale: Awareness of medication side effects allows the patient and family
to take necessary precautions and report any adverse effects to the
healthcare provider for appropriate management.
Encourage the use of non-skid footwear and ensure proper fitting shoes.
● Rationale: Non-skid footwear provides better traction and reduces the risk of
slipping, while properly fitting shoes improve stability and support, decreasing
the likelihood of falls.
Evaluate pain relief and control at regular intervals. Adjust medication regimen
as necessary.
The goal is maximum pain control with minimum interference with ADLs.
Inform the patient and SO of the expected therapeutic effects and discuss the
management of side effects
This information helps establish realistic expectations and confidence in own ability
to handle what happens.
Monitor daily food intake; have the patient keep a food diary as indicated.
Identifies nutritional strengths and deficiencies.
Measure height, weight, and tricep skinfold thickness (or other anthropometric
measurements as appropriate). Ascertain the amount of recent weight loss.
Weigh daily or as indicated.
If these measurements fall below minimum standards, the patient’s chief source of
stored energy (fat tissue) is depleted.
Assess skin and mucous membranes for pallor, delayed wound healing, and
enlarged parotid glands.
Helps in the identification of protein-calorie malnutrition, especially when weight and
anthropometric measurements are less than normal.
Monitor I&O and specific gravity; include all output sources, (emesis, diarrhea,
draining wounds. Calculate 24-hr balance).
Continued negative fluid balance, decreasing renal output, and concentration of
urine suggest developing dehydration and the need for increased fluid replacement.
Weigh as indicated.
Sensitive measurement of fluctuations in fluid balance.
Adjust diet before and immediately after treatment (clear, cool liquids, light or
bland foods, candied ginger, dry crackers, toast, and carbonated drinks). Give
liquids 1 hr before or 1 hr after meals.
The effectiveness of diet adjustment is very individualized in the relief of posttherapy
nausea. Patients must experiment to find the best solution or combination. Avoiding
fluids during meals minimizes becoming “full” too quickly.
Identify the patient who experiences anticipatory nausea and vomiting and
take appropriate measures.
Psychogenic nausea and vomiting occurring before chemotherapy generally do not
respond to antiemetic drugs. A change of treatment environment or patient routine
on treatment day may be effective.
Insert and maintain NG or feeding tube for enteric feedings, or central line for
total parenteral nutrition (TPN) if indicated.
In the presence of severe malnutrition (loss of 25%–30% body weight in 2 mo) or if
the patient has been NPO for 5 days and is unlikely to be able to eat for another
week, tube feeding or TPN may be necessary to meet nutritional needs.
Have the patient rate fatigue, using a numeric scale, if possible, and the time of
day when it is most severe.
Helps in developing a plan for managing fatigue.
Assist with self-care needs when indicated; keep the bed in a low position, and
pathways clear of furniture; assist with ambulation.
Weakness may make ADLs difficult to complete or place the patient at risk for injury
during activities.
Assess skin frequently for side effects of cancer therapy; note breakdown and
delayed wound healing. Emphasize the importance of reporting open areas to
the health care providers.
A reddening or tanning effect (radiation reaction) may develop within the field of
radiation. Dry desquamation (dryness and pruritus), moist desquamation (blistering),
ulceration, hair loss, and loss of dermis and sweat glands may also be noted. In
addition, skin reactions (allergic rashes, hyperpigmentation, pruritus, and alopecia)
may occur with some chemotherapy agents.
Assess skin and IV site and vein for erythema, edema, tenderness; welt-like
patches, itching and burning; or swelling, burning, soreness; blisters
progressing to ulceration or tissue necrosis.
The presence of phlebitis, vein flare (localized reaction), or extravasation requires
immediate discontinuation of antineoplastic agents and medical intervention.
Encourage the patient to avoid vigorous rubbing and scratching and to pat the
skin dry instead of rubbing.
Helps prevent skin friction and trauma to sensitive tissues.
Review skin care protocol for patients receiving radiation therapy: Avoid
rubbing or the use of soap, lotions, creams, ointments, powders, or
deodorants on the area.
Designed to minimize trauma to the area of radiation therapy. Can potentiate or
otherwise interfere with radiation delivery. May actually increase irritation and
reaction. Skin is very sensitive during and after treatment, and all irritation should be
avoided to prevent dermal injury.
Avoid applying heat or attempting to wash off marks or tattoos placed on the
skin to identify the area of irradiation.
Helps control dampness or pruritus. Maintenance care is required until skin and
tissues have regenerated and are back to normal.
Recommend wearing soft, loose cotton clothing; have female patients avoid
wearing bras if it creates pressure.
Protects skin from ultraviolet rays and reduces the risk of recall reactions.
Wash skin immediately with soap and water if antineoplastic agents are spilled
on unprotected skin (patient or caregiver).
Dilutes drug to reduce the risk of skin irritation and chemical burn.
Inform the patient that if alopecia occurs, hair could grow back after
completion of chemotherapy, but may or may not grow back after radiation
therapy.
Anticipatory guidance may help in preparation for baldness. Men are often as
sensitive to hair loss as women. Radiation’s effect on hair follicles may be
permanent, depending on radiation dosage.
Review the patient’s and SO’s previous experience with cancer. Determine
what the doctor has told the patient and what conclusion the patient has
reached.
Clarifies patient’s perceptions; assists in the identification of fear(s) and
misconceptions based on diagnosis and experience with cancer.
Identify the stage and degree of grief the patient and SO are currently
experiencing.
The choice of interventions is dictated by the stage of grief, and coping behaviors
(anger, withdrawal, denial).
Maintain frequent contact with the patient. Talk with and touch the patient as
appropriate.
Provides assurance that patient is not alone or rejected; conveys respect for and
acceptance of the person, fostering trust.
Explain the recommended treatment, its purpose, and potential side effects.
Help patients prepare for treatments.
The goal of cancer treatment is to destroy malignant cells while minimizing damage
to normal ones. Treatment may include surgery (curative, preventive, palliative), as
well as chemotherapy, radiation (internal, external), or organ-specific treatments
such as whole-body hyperthermia or biotherapy. Bone marrow or peripheral
progenitor cell (stem cell) transplant may be recommended for some types of cancer.
Consider reports of pain, noting location and intensity (scale of 0–10). Note
precipitating factors and nonverbal pain cues.
Favorable in determining pain management needs and effectiveness of the program.
Place and monitor the use of pillows, sandbags, trochanter rolls, splints, and
braces.
Rests painful joints and maintains a neutral position. Note: The use of splints can
decrease pain and may reduce damage to joints; however, prolonged inactivity can
result in loss of joint mobility and function.
Assist with physical therapies such as paraffin gloves, and whirlpool baths.
Provides sustained heat to reduce pain and improve ROM of affected joints.
Instruct in use and monitor the effect of the transcutaneous electrical nerve
stimulator (TENS) unit if used.
Constant low-level electrical stimulus blocks the transmission of pain sensations.
Impaired physical imboloty related to intolerance ro activity; reduced muscle
strength
Assess and continuously monitor the degree of joint inflammation and pain.
The level of activity and exercise depends on the progression and resolution of the
inflammatory process.
Assist with active and passive ROM and resistive exercises and isometrics
when able.
Maintains and improves joint function, muscle strength, and general stamina. Note:
Inadequate exercise leads to joint stiffening, whereas excessive activity can damage
joints.
Encourage the patient to maintain an upright and erect posture when sitting,
standing, and walking.
Maximizes joint function, and maintains mobility.
Urge the patient to perform activities of daily living (ADLs), such as practicing
good hygiene, dressing, and feeding himself.
ADLs that can be done should be encouraged to maximize function.
Discuss and provide safety needs such as raised chairs and toilet seats, use
of handrails in the tub, shower, and toilet, proper use of mobility aids, and
wheelchair safety.
Helps prevent accidental injuries and falls.
Position with pillows, sandbags, and trochanter roll. Provide joint support with
splints, and braces.
Promotes joint stability (reducing risk of injury) and maintains proper joint position
and body alignment, minimizing contractures.
Encourage verbalization about concerns about the disease process, and future
expectations.
Provides an opportunity to identify fears and misconceptions and deal with them
directly.
Encourage a balanced diet, but make sure the patient understands that special
diets won’t cure RA. Stress the need for weight control.
Obesity adds further stress to joints.
Ascertain how the patient views self in usual lifestyle functioning, including
sexual aspects.
Identifying how illness affects the perception of self and interactions with others will
determine the need for further intervention and counseling.