Nursing Care for Older Adults and Common Health Conditions, Summaries of Nursing

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Regulated and Unregulated

Health Care Providers: Roles and

Responsibilities

Holistic Care

Holistic care involves considering the whole person, including their physical, social, emotional, cognitive, and spiritual dimensions. It is an approach that looks at the individual as a complete being, rather than just focusing on specific symptoms or medical conditions.

Professionalism

Professionalism is an approach to work that demonstrates respect for others, commitment, competence, and appropriate behaviors. It involves maintaining high standards of conduct and ethics in one's professional role.

Professional Boundaries

Professional boundaries are appropriate limitations on behavior, meant to protect the vulnerable client from the caregiver who has access to private knowledge about them. These boundaries help maintain a clear and appropriate relationship between the caregiver and the client.

Regulation of a PSW

Personal Support Workers (PSWs) are an unregulated profession. There is no legislation to regulate PSWs or an organization of professional college that governs their role. However, they must adhere to the codes of behavior from their employer.

Regulated Health Professions Act

In Ontario, regulated health professions are governed under the Regulated Health Professions Act, 1991 (RHPA) and health profession Acts (e.g., Medicine Act, 1991). This legislative framework establishes health regulatory colleges, which regulate the professions in the public interest, such as the College of Nurses.

Role of the Occupational Therapist

Occupational therapists focus on rehabilitation, teaching clients the skills needed to perform activities of daily living (ADLs), and designing adaptive equipment for ADLs.

Role of the Physical Therapist

Physical therapists focus on rehabilitation, assisting clients with musculoskeletal impairments, and restoring function and preventing disability from illness or injury.

Role of Registered Nurse (RN)

Registered nurses assess, make nursing diagnoses, plan, implement, and evaluate nursing care. They tend to clients with unstable health conditions, provide direct client care, administer medications, and supervise support workers.

Role of Registered Practical Nurse (RPN) / Licensed

Practical Nurse (LPN)

Registered practical nurses (RPNs), also known as licensed practical nurses (LPNs) in some provinces, are health care providers licensed and regulated by the province or territory to carry out nursing techniques and provide client care.

Delegation of Tasks

All Rules Regarding Delegation

Only regulated health care providers like nurses have the authority (legal right) to perform certain tasks, as they have the knowledge, skill, and training to do so. These tasks are called controlled acts and are considered harmful if performed by unqualified people. In some circumstances, some acts may be delegated to unregulated workers, but specific conditions called 'exceptions' must be met for delegation to be permitted.

Before Delegating Tasks, the Nurse Must Know:

What tasks the province or territory allows support workers to perform The tasks included in the support worker's job description What the support worker was taught in their training program The support worker's work experiences What skills the support worker has learned and how they were evaluated

Nurse's Responsibilities When Delegating Tasks

Have the knowledge, skill, and judgment to perform the task competently Have the additional knowledge, skill, and judgment to teach the task to others Accept responsibility for teaching the task to the support worker Assess the support worker's performance and determine if they can perform the task correctly

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Monitor the support worker over time to ensure they remain able to perform the task correctly and safely

Reasons to Refuse a Delegated Task

The support worker has concerns about their ability to do the task The task is beyond the support worker's scope of practice The client's condition has changed

The Right Task, Circumstances, Person, Directions/

Communication, and Supervision/Evaluation

When delegating tasks, the nurse must ensure the following:

The Right Task: Can the task be delegated? Is it in the support worker's job description? Have they been trained to do it? The Right Circumstances: What are the client's current needs? Do you have the necessary equipment and supplies? The Right Person: Does the support worker have the training and experience to safely perform the task for this client? The Right Directions and Communication: Has the nurse provided clear instructions and can the support worker review the task with the nurse? The Right Supervision and Evaluation: Is a nurse available to answer questions and assess the impact of the task on the client? Does the nurse discuss the support worker's performance with them?

Culture

Culture refers to the characteristics of a group of people, including their language, values, beliefs, customs, habits, ways of life, rules for behavior, music, and traditions. Culture is what makes a society distinctive and is learned by living in a group, influencing a person's behaviors and attitudes.

Culture and Religion

Ethnicity is an important influence on a person's culture, but it is not the only influence. Religion is also very important in most cultures, as it relates to spiritual beliefs, needs, and practices. Clients may want to engage in certain religious practices during illness, which should be promptly reported to the supervisor.

Maslow's Hierarchy of Needs

According to Maslow's theory, certain basic needs must be met for a person to survive and function. These needs are arranged in a hierarchy, with lower- level needs (physical, safety) needing to be met before higher-level needs (love and belonging, self-esteem, self-actualization).

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Legal Concepts

Charter of Rights and Freedoms

The Charter of Rights and Freedoms is federal legislation that applies to all Canadians, regardless of where they live. It includes freedoms of conscience, religion, thought, belief, opinion, expression, peaceful assembly, and association, as well as the right to vote, the right to life, liberty and security, and the right to equality before and under the law.

Assault

Assault is identified in Canada's Criminal Code and can be defined as intentionally attempting or threatening to touch a client's body without the client's consent, causing the client to fear bodily harm.

Battery

Battery (part of tort law) is the actual intentional touching of a client's body without the client's consent.

Slander

Slander is making harmful false statements orally.

Negligence

Negligence is when a person fails to act in a careful or competent manner and thereby harms the client or damages property. It is an unintentional wrong, but the person failed to do what a reasonable or careful person would have done or not done.

False Imprisonment

False imprisonment is the unlawful restraint or restrictions on a person's freedom of movement, such as preventing someone from leaving a facility or the unnecessary use of restraints.

Harassment

Harassment is troubling, tormenting, offending, or worrying a person through one's behavior or comments.

Autonomy

Autonomy is the freedom and choice to make decisions that affect one's life, also known as self-determination.

Dependence

Dependence is the state of relying on others for support, being unable to manage without help.

Interdependence and Independence

Interdependence

Interdependence is the state of relying on one another.

Independence

Independence is the state of not relying on others for control or authority.

Client Rights

Rights of Clients

Clients have the following rights: - The right to be treated with dignity and respect - The right to privacy and confidentiality - The right to give or withhold informed consent - The right to autonomy

Rights of Long-Term Care Clients

Residents' Bill of Rights

Every licensee of a long-term care home shall ensure that the following rights of residents are fully respected and promoted:

The right to be treated with courtesy and respect and in a way that fully recognizes the resident's individuality and respects the resident's dignity. The right to be protected from abuse. The right not to be neglected by the licensee or staff. The right to be properly sheltered, fed, clothed, groomed and cared for in a manner consistent with their needs. The right to live in a safe and clean environment. The right to exercise the rights of a citizen. The right to be told who is responsible for and who is providing the resident's direct care. The right to be afforded privacy in treatment and in caring for their personal needs. The right to have their participation in decision-making respected. The right to keep and display personal possessions, pictures and furnishings in their room subject to safety requirements and the rights of other residents. The right to: i. Participate fully in the development, interpretation, review and revision of their plan of care. ii. Give or refuse consent to

any treatment, care or services for which their consent is required by law and to be informed of the consequences of giving or refusing consent. iii. Participate fully in making any decision concerning any aspect of their care, including any decision concerning their admission, discharge or transfer to or from a long-term care home or a secure unit and to obtain an independent opinion with regard to any of those matters. iv. Have their personal health information within the meaning of the Personal Health Information Protection Act, 2004 kept confidential in accordance with that Act, and to have access to their records of personal health information, including their plan of care, in accordance with that Act. The right to receive care and assistance towards independence based on a restorative care philosophy to maximize independence to the greatest extent possible. The right not to be restrained, except in the limited circumstances provided for under this Act and subject to the requirements provided for under this Act. The right to communicate in confidence, receive visitors of their choice and consult in private with any person without interference. The right, if they are dying or are very ill, to have family and friends present 24 hours per day. The right to designate a person to receive information concerning any transfer or any hospitalization of the resident and to have that person receive that information immediately. The right to raise concerns or recommend changes in policies and services on behalf of themselves or others to various persons and organizations without interference and without fear of coercion, discrimination or reprisal. The right to form friendships and relationships and to participate in the life of the long-term care home. The right to have their lifestyle and choices respected. The right to participate in the Residents' Council. The right to meet privately with their spouse or another person in a room that assures privacy. The right to share a room with another resident according to their mutual wishes, if appropriate accommodation is available. The right to pursue social, cultural, religious, spiritual and other interests, to develop their potential and to be given reasonable assistance by the licensee to pursue these interests and to develop their potential. The right to be informed in writing of any law, rule or policy affecting services provided to the resident and of the procedures for initiating complaints. The right to manage their own financial affairs unless the resident lacks the legal capacity to do so. The right to be given access to protected outdoor areas in order to enjoy outdoor activity unless the physical setting makes this impossible. The right to have any friend, family member, or other person of importance to the resident attend any meeting with the licensee or the staff of the home.

Communication Techniques

Active Listening

Active listening involves paying close attention to a client's verbal and nonverbal communication, listening to the content, the intent and feelings behind the words. Guidelines for active listening include: - Facing the client and making eye contact (considering cultural preferences) - Leaning towards the client (avoiding crossed arms) - Responding to the client (but allowing them to vent) - Avoiding communication barriers like interrupting, answering your own questions, giving advice, minimizing problems, using patronizing language, or failing to listen.

Paraphrasing

Paraphrasing involves restating another person's message in your own words, usually using fewer words than the original message. It serves three purposes: 1. It shows that you are listening. 2. It lets both you and the sender know that you understood the message. 3. It promotes further communication. It's important not to interpret the client's words.

Empathetic Listening

Empathetic listening requires being attentive to the speaker's feelings. Empathy means being open to and trying to understand the experiences and feelings of others. It involves acknowledging the other person's point of view without judging. Empathy can reduce feelings of loneliness and sadness and can create trust between the support worker and clients.

Asking Closed Questions

Closed questions focus on specific information and require a yes/no or brief response.

Asking Open-Ended Questions

Open-ended questions invite a person to share their thoughts, feelings, or ideas. Answers must be more than a yes or no. The person being questioned chooses and controls what is talked about and the information given. Using both open and closed ended questions can help find out about a client's needs and preferences and determine if a client is satisfied with their care.

Clarifying

Clarifying ensures that you understand a person's message. You can ask the client to repeat the message, say you don't understand, or restate the message as a question.

Focusing

Focusing limits the conversation to a certain topic. It's useful when a client rambles or wanders in thought. You can give the client 2 choices to focus the discussion.

Data Collection

Objective Data (Signs)

Objective data is the information you gather while using your senses.

Subjective Data (Symptoms)

Subjective data is information reported by a client but not directly observed by the support worker. When reporting subjective data, do not interpret the client's words, quote the client directly.

Use of Restraints

Review of Restraint Use

Restraints are any device, garment, barrier, furniture, or medication that limits or restricts freedom of movement or access to one's own body. Every effort should be made to protect clients without resorting to the use of restraints, as restraints can cause emotional harm and serious physical injury.

Guidelines for Use of Restraints

Restraints require a physician's order, after consultation with the client's family. Support workers never decide if restraints are to be used. Unnecessary restraint is false imprisonment. There must be written consent in the client's chart for using restraints. Restraints are never used to discipline a client or for staff convenience, only in the way the physician ordered. Always try to determine the reason for the client's agitation or behaviour and address the underlying cause to prevent the need for restraints. Restraint use should always be avoided. Restraint alternatives should always be part of the care plan. Informed consent is required, where the client must understand the reason for the restraint, how it will help, and the risks. Restraints are only used in extreme cases and when necessary to prevent harm. The least restrictive method is used, following the manufacturer's instructions. Non-restraint items must never be used. Restraints are only applied by trained and knowledgeable staff.

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The client's basic needs are met, and they are observed at least every 15 minutes or more often as required. The restraint is removed, the client is repositioned, and basic needs are met at least every 2 hours. Information about restraints must be recorded in the client's care plan.

Fire Safety

It is essential to have working fire detectors on every floor of the home and ideally outside of the sleeping area. Identify where the smoke detectors are and notify your supervisor if they are not working.

THINK ABOUT SAFETY

Smoking Safety

Smoke only in designated areas, not in clients' homes. Supervise clients who smoke, especially if they are confused, disoriented, or sedated. Provide ashtrays for clients who are allowed to smoke. Check smoking areas for dropped cigarettes or ashes, especially on furniture. Ensure all cigars and cigarettes are extinguished before emptying ashtrays. Empty ashtrays into metal containers with sand or water, not into plastic or paper-lined wastebaskets. Do not allow clients to smoke in bed or while lying down. Do not ignite lighters or matches near flammable liquids or materials. Keep matches and lighters out of the reach of children.

Fire Safety

Avoid deep-frying in oil, as oil is highly flammable. Do not drape tea towels or other materials over the oven door. Use potholders, not tea towels, to remove hot items from the oven. Follow manufacturers' instructions when using space heaters, keeping them at least 1m (3ft) from curtains, drapes, and furniture, and do not leave them unattended. Keep flammable materials and liquids away from fireplaces, radiators, heat registers, and other sources of heat or flame. Store flammable liquids in their original containers. Do not run electrical cords under carpets. Use extension cords only as a temporary measure.

RACE Acronym

R - Rescue: Move people in immediate danger to a safe place. A - Alarm: Sound the nearest fire alarm and call 911 if in a client's home.

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C - Confine: Close doors and windows to confine the fire. Turn off oxygen or electrical equipment in the general area of the fire. E - Extinguish/Evacuate: Use a fire extinguisher on a small fire that hasn't spread to a larger area. If the fire is not contained, evacuate the area.

Fire Escape Planning

When entering a client's home for the first time, plan at least two fire escape routes from every room. In an apartment building, identify the fire alarms in the hallways in case they are needed.

Standard Practices for Infection Prevention

Hand Hygiene

Wash hands after touching blood, bodily fluids, secretions, excretions, non-intact skin, and mucous membranes, even if gloves were worn. Wash hands immediately before and after wearing gloves. Wash hands between clients and between tasks and procedures on the same client to avoid cross-contamination. Use plain soap for routine hand washing.

Gloves

Wear gloves when touching blood, bodily fluids, secretions, excretions, non-intact skin, and mucous membranes. Change gloves between tasks and procedures on the same client and after contact with material that may be highly contaminated. Remove gloves promptly after use, before touching uncontaminated items and surfaces, and before going to another client. Practice hand hygiene immediately after removing gloves.

Masks and Eye Protection

Wear during procedures and tasks that are likely to cause splashes of blood, body fluids, secretions, or excretions to protect your eyes and mouth from contact with sprays or splashes.

Gowns

Wear during procedures and tasks that are likely to cause splashes of blood, body fluids, secretions, or excretions to protect your clothing from contamination. A clean, non-sterile gown is adequate. Remove the gown as soon as possible and practice hand hygiene after removal to prevent the spread of microbes.

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Care of Equipment

Handle equipment carefully, ensuring it does not touch your skin, mucous membranes, or clothing. Do not use reusable items for another client without first disinfecting or sterilizing them. Discard disposable (single-use) items properly.

Environmental Control

Follow your employer's guidelines for regular disinfection of surfaces.

Linen

Follow your employer's policy for dealing with soiled linens. Do not touch soiled linen with your skin, mucous membranes, or clothing. Do not shake linens to prevent the spread of microbes.

Occupational Health and Blood-Borne Pathogens

Use extreme care when handling sharps (anything that can pierce the skin). Never recap used needles, handle them with one hand, or remove them from a disposable syringe or needle. Place used sharps in the proper disposable containers. Use barrier devices for rescue breathing in emergencies.

Client Placement

Use a private room if the client contaminates the area, does not or cannot assist in maintaining hygiene or environmental control. Follow your supervisor's instructions if a private room is not available.

Fall Prevention

Signs and Symptoms of Infection

Fever and chills Increased pulse and respiratory rates Aches, pain, or tenderness Fatigue and loss of energy Loss of appetite Nausea, vomiting, or diarrhea Rash or sores on mucous membranes Redness and swelling of a body part Discharge or drainage from the infected area with a foul odor New or increased cough, sore throat, or runny/stuffy nose Burning pain when urinating or the need to urinate more often or with increased urgency

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Behavioral changes in older adults

Strategies to Prevent Falls

Assess the client's falls risk and provide extra supervision and assistance for those at high risk. Educate staff on how to safely move clients and use equipment to avoid injuries. Use methods to identify falls risk, such as color-coded bracelets or signs above the client's bed, in a respectful manner. Ensure bedrooms, bathrooms, and stairs are as safe as possible, with well-lit and clutter-free areas. Provide adequate time and reminders for clients to ask for help if needed. Keep hallways well-lit and free of clutter, especially during shift changes. Report and address any unsecured small rugs or mats, damaged flooring, or lumpy carpets. Keep cords off the floor and use only non-glare, non-slip floor wax. Maintain a clear path from the bedroom to the bathroom. Ensure wheelchair locks are in working order and position the client properly. Encourage clients to wear hearing aids and glasses whenever applicable. Use electric warning devices and respond to alarms promptly. Provide floor cushions as a softer landing if the client falls out of bed. Be cautious when turning corners in facilities, as you may not always see around them. Perform a safety check after visitors have left, as they may not be aware of the precautions involved with your client.

Proper Body Alignment and Transferring

Clients

Good Body Alignment

Maintain a relatively low center of gravity, with the head and neck erect and straight, shoulders and hips parallel, shoulders back, chest out, and a natural lumbar curve. Keep the abdomen tucked in, the pelvis tilted in, and the knees slightly flexed. Position the arms comfortably at the sides, with the feet about shoulder-width apart and the toes pointing forward, with one foot slightly forward.

Transferring Clients

Ensure the client is wearing non-skid footwear to prevent sliding or slipping. The chair or wheelchair must be able to support the client's weight.

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Use transfer boards to assist with sliding from the bed to a chair or wheelchair when the client can assist with the transfer. Cover the back and seat of the chair with a folded blanket, and place a small pillow or cushion behind the client if instructed. Promote the client's comfort, prevent pressure ulcers, and maintain proper posture during the transfer.

Bones that Weight Bear

The long bones that weight bear are the femur, tibia, and fibula.

Turning Immobile Patients

Turn immobile patients at least every 2 hours, or as directed by the care plan, to prevent pressure ulcers.

Friction and Shearing

Friction is the resistance the skin encounters when it rubs against another surface, such as clothing, bedding, or another fold of skin. Shearing is the tearing of skin tissues caused when the skin sticks to a surface (usually the bed or chair) and deeper tissues move downward, exerting pressure on the skin. Shearing can happen when a client slides down in bed or is moved in bed, and it can be very painful and lead to serious skin and health problems.

Muscular Atrophy and Contractures

Muscular atrophy is the decrease in size or wasting away of muscles, a complication from lack of exercise that must be prevented. Contractures are the lack of joint mobility caused by abnormal shortening of a muscle.

Body Movements

Flexion is the bending of a body part. Abduction is the movement of a body part away from the midline of the body. Adduction is the movement of a body part toward the midline of the body.

Types of Abuse

Abuse

Abuse is physical or mental harm caused by someone in a position of trust.

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Physical Abuse

Physical abuse is force or violence that causes pain, injury, and sometimes death, such as pinching, hair pulling, kicking, choking, burning, poisoning, or throwing things.

Sexual Abuse

Sexual abuse is unwanted sexual activity, such as rape, attempted rape, unwanted touching, fondling, kissing, and exposure. Sexual harassment is another form of sexual abuse, involving any conduct, comment, gesture, threat, or suggestion that is sexual in nature.

Emotional (Psychological) Abuse

Emotional abuse involves words or actions that cause mental harm, usually through an attack on a person's self-esteem, insulting, humiliating, or rejecting them. It can happen to infants, children, teens, adults, and older adults, and may involve not allowing the client to do their preferred activities or visit with friends and family, or threatening to harm someone or something the victim loves.

Financial Abuse

Financial abuse is the misuse of a person's money or property, usually for the abuser's financial gain. It includes stealing, forging signatures, selling property or possessions without permission, and persuading or tricking victims to change their wills or give up control of their finances.

Neglect and the Cycle of Abuse

Neglect

Neglect is the failure to meet the basic needs of a dependent person, such as children, people with disabilities, and frail older adults. Neglect can occur when a clean, comfortable, and safe environment is not provided. Neglect can be intentional or unintentional.

The Cycle of Abuse

The cycle of abuse consists of three phases:

The tension-building phase: Everyday events and comments irritate the abuser, who becomes more aggressive. The victim may try to calm, soothe, and please the abuser or stay out of the abuser's way.

The abusive phase: Tension explodes into an abusive event, which may involve neglect or physical, sexual, emotional, or financial abuse. The abuse is often triggered by an event unrelated to the victim's behavior.

The honeymoon phase: The abuser feels ashamed or sorry, apologizes, and promises never to do it again. The abuser and the victim may believe the abuser can change.

The Role of the Personal Support Worker

(PSW) and Abuse

Responding to Abuse

If a client or child tells you about being abused, it is important to:

Listen attentively and let the client tell you what happened in their own words. Reassure the client that you believe what they have said. Stay calm and do not show anger or disgust. Assure the client that you will do whatever you can to help. Notify your supervisor at once and follow your employer's policies. Provide emotional support, regardless of the client's decision. You cannot force a client to make a certain decision, but those who cannot make their own decisions must get the help of a professional.

Your Legal Responsibility

Every Canadian province and territory has legislation that imposes a duty to report if a child, a person with physical or mental challenges, or an older adult is being abused by a parent, adult child, caregiver, or guardian. Support workers have this duty as well. Report your concerns to the child welfare agency, the provincial/territorial social services department, or the police. Reporting is not time-consuming and can be done anonymously. There are laws to protect against legal action, provided the reports are not falsely made and motivated by malice.

Nutrition

Basic Nutrition

Nutrition refers to the processes involved with ingestion, digestion, absorption, and use of foods and fluids by the body. Ingestion is the process of taking food and fluids into the body. Digestion is the process of physically and chemically breaking down nutrients so that they can be absorbed for use by the cells. Absorption is the process by which substances pass through the intestinal wall into the blood.

Good nutrition is needed for growth, healing, and maintenance of body functions. Those who follow the recommendations in the Canadian Food Guide will obtain all the nutrients they need for a balanced diet.

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Nutrients

Food and fluids contain nutrients, which are substances that are ingested, digested, absorbed, and used by the body. They are grouped into six categories: Protein, Carbohydrates, Fats, Vitamins, Minerals, and Water.

Protein

Needed for tissue growth and repair. Sources include meat, fish, eggs, milk, peas, and nuts. Animal products are the highest in proteins, so those who do not eat meat must ensure they are taking in enough protein. Protein deficiency can result in severe malnutrition, which affects children and older adults more.

Carbohydrates

Provide energy for the body and fiber for bowel elimination. Most carbohydrates come from plants. There are three kinds of carbohydrates: simple sugars, starches, and fiber. During digestion, most carbohydrates (except fiber) are broken down into sugars, which are then absorbed into the bloodstream.

Fats

Provide energy, help the body use certain vitamins, and add flavor to food. Some fat is needed, but fat that is not needed will be stored as body fat. There are three types of fat: saturated fat, trans fat, and unsaturated fat.

Vitamins

Needed daily for normal function and growth, but they do not provide calories. Each vitamin is needed for specific body functions. Excess doses of fat-soluble vitamins (A, D, E, and K) can cause complications, while vitamins C and B in excess amounts are excreted through the urine.

Minerals

Chemical substances found in both plant and animal foods. Each mineral is needed for specific body functions, such as calcium and phosphorus for strong bones and teeth.

Water

The most important nutrient necessary for life. The body needs water for maintaining cell function, regulating body temperature, delivering nutrients, removing waste, and performing other bodily processes. The amount of fluid taken and lost must be in balance, as death can result from inadequate water intake or excessive fluid loss.

Fluid Requirements

1500 ml/day for survival 2000-2500 ml/day for normal fluid balance

Guidelines for Feeding Clients

Check care plans for any food or liquid allergies or intolerances Review and check expiry dates when shopping for a client Do not substitute ingredients when cooking without the client's permission Follow the care plan when feeding a client Use spoons, not forks Sit facing the client to see signs of choking or swallowing difficulty Offer fluids during the meal to help with chewing and swallowing Gently stroke the client's cheek to rouse them if they fall asleep while eating

Aging and Older Adults

The Aging Population

The number of older adults is increasing as people are living longer. Older people have knowledge, wisdom, and experience that we can all benefit from. Canada is increasing its efforts to better understand the implications of the aging population on health and long-term care needs and costs. 'Active Aging' is becoming the norm, meaning that older adults are increasingly contributing to society through paid and unpaid activities.

Gerontology and Geriatrics

Gerontology is the study of the aging process, while geriatrics is the branch of medicine that provides care for older adults.

The Developmental Tasks of Late Adulthood

The developmental tasks of late adulthood are as follows: - Adjusting to decreased physical strength and loss of health - Adjusting to retirement and reduced income - Coping with the death of a partner - Developing new friends and relationships - Preparing for one's own death

Caring for Older Clients

Mainstream culture in North America tends to overvalue youth. Treating older people as if they are boring, useless, or childlike is ageism, which threatens their dignity and sends the message that they are no longer useful, productive members of society. To care for older clients effectively, you need to understand the emotional, social, and physical changes that occur with aging.

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Retirement

Retirement is often a person's first real experience with aging. More people are looking to further their education in retirement, and most enjoy their retirement, but some are not so fortunate. Some are forced to retire because of a persistent illness, disability, or poor health.

Work and Social Relationships

Work has social and emotional effects, as it helps meet the basic needs of love, belonging, and self-esteem, and brings a sense of fulfillment and usefulness. Some people use the time after retirement to pursue hobbies and goals, but if a person hasn't cultivated any interests outside of work, retirement can be abrupt and upsetting. Always report signs of depression or expressions of sadness after a client has retired.

Reduced Income

Retirement income is often less than half of a person's full income during their working years. For some, CPP may be the only source of income, but CPP hasn't kept up with the rising cost of living. More people qualify for OAS (Old Age Security) than CPP, as OAS is not employment-dependent. Reduced income may lead to limiting social and leisure activities, finding cheaper housing, or moving in with children or other relatives.

Social Relationships

Social relationships change over time. People move away, have families of their own, and other relationships end due to death. Some older adults develop mobility issues that may interfere with their hobbies or getting around. A support worker may be the only visitor the client has.

Children as Caregivers

Sometimes parents and children exchange roles, which may lead to a loss of dignity and self-respect. This role change can also be stressful, and lack of privacy can be a stressor.

Death of a Partner, Significant Other, or Pet

Women live longer than men and therefore will typically become widows. Even if a person thinks they are emotionally prepared for a death, the loss can be devastating and lead to serious physical and mental health problems.

Depression in Older Adults

Depression is not an inevitable part of aging, but it can go unnoticed because the signs and symptoms occur gradually and can be confused with dementia. Depression increases the chance of death in older adults by two or three times. Report any signs of depression to your supervisor.

Common Therapies for Depression

Cognitive Behavioral Therapy Interpersonal Therapy Problem-Solving Therapy Reminiscence Therapy

Common Signs of Depression in Older Adults

Sadness Loss of energy and feeling of tiredness Memory problems Irritability Neglecting personal care Loss of interest in hobbies or interests Reluctance to be with friends or engage in activities Difficulty falling asleep or staying asleep Oversleeping Feelings of being burdensome or worthless Increased use of alcohol or medications Fixation on death or suicidal thoughts Increase in physical complaints, such as arthritis or headaches

Physical Changes with Aging

Integumentary System

Skin becomes less elastic Skin loses its strength Brown spots ('age spots' or 'liver spots') appear on the wrists and hands Nerve endings decrease in number Blood vessels decrease in numbers Fatty tissue layer is lost Skin thins and sags Skin becomes fragile and easily injured Folds, lines, and wrinkles appear Secretion from oil and sweat glands decreases Skin becomes dry Skin becomes itchy Sensitivity to extreme heat and cold environments decreases Sensitivity to pain decreases Nails become thick and tough Hair whitens or greys Hair thins Facial hair appears on some women Hair becomes dry

Musculoskeletal System

Muscles atrophy

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Strength decreases Bones become brittle and can break easily Joints become stiff and painful Height gradually decreases Mobility decreases

These physical changes are a normal part of aging and occur in everyone, though the rate and degree of change are different for each individual. They are influenced by factors such as diet, general health, exercise, stress, environment, and heredity. Normal aging does not mean a loss of health.

Nervous System

Vision and Hearing Decrease

Senses of taste, smell, and touch decrease Sensitivity to pain is reduced Blood flow to the brain is reduced Cells shrink Memory becomes shorter (forgetfulness) Ability to respond slows Sleep patterns change Dizziness occurs

Circulatory System

Heart pumps with less force Arteries narrow and are less elastic Less blood flow through narrowed arteries Weakened heart has to work harder to pump blood through narrowed vessels

Respiratory System

Respiratory muscles weaken Lung tissues become less elastic Breathing becomes difficult Strength for coughing decreases

Digestive System

Saliva production decreases Swallowing becomes difficult Appetite decreases Secretion of digestive juices decreases Digesting fried and fatty foods becomes difficult Ingestion occurs Teeth fall out Peristalsis decreases, causing flatulence and constipation

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Urinary System

Blood supply to kidneys is reduced Kidneys atrophy Kidney function decreases Urine becomes concentrated Urinary frequency, urgency, and incontinence may occur Nighttime urination may occur

Female Reproductive System

Menstruation stops Estrogen production decreases Ovaries and uterus decrease in size Vaginal walls become thinner, drier, and less elastic Fat and elastic tissue in external genitalia decrease Breasts become less firm

Male Reproductive System

Testosterone production decreases Force of ejaculation decreases Sperm count is reduced Testes become smaller Prostate gland enlarges Erections develop more slowly

The Older Adult and Sexuality

Love, affection, and intimacy are needed throughout life, as sexuality is part of the whole person Some older people are not able to have sexual intercourse, but that does not mean the desire has gone They can express these needs through hand holding, touching, caressing, and embracing Members of the health care team must respect their clients' sexuality and allow and promote ways to meet their sexual needs

Respecting and Promoting the Client's

Sexuality

Respect your client's clothing and grooming routines Accept the client's sexual relationships Allow privacy (knock before entering a room)

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Bathing and Oral Care - Nursing

Consideration

Bathing helps keep the skin, genital, and anal areas clean by removing microbes, dead skin, perspiration, and excess oils A bath is relaxing, stimulates circulation, and exercises body parts During baths, you're able to make important observations about clients and have time to get to know them The client may require a complete bath, a tub bath, or a shower depending on their condition, self-care ability, and personal choice

Complete Bed Bath

Involves washing the entire body while the client is still in bed It is given to clients who cannot bathe themselves, clients who are unconscious, paralyzed, in casts or traction, or weak from illness or surgery

Towel Baths

Usually an oversized towel is used to cover the client's body The towel is saturated with a cleaning solution containing water, a cleaning solution, and a skin softening agent Clients with dementia often accept this type of bath well

Bag Baths

A prepackaged bath containing moist washcloths that are heated in the microwave No towel is needed as the skin is air-dried

The Partial Bath

Involves bathing the face, hands, axillae (underarms), back, buttocks, and perineal area These areas develop odors or cause discomfort if they are not clean Partial baths are given to clients who cannot bathe themselves

Tub Baths & Showers

Some clients prefer tub baths, and some prefer showers Falls and burns from hot water can occur, so ensuring safety is key Tub baths can cause a client to feel faint, weak, or tired, especially for those on bed rest Showers have different options available in different facilities, and clients either walk in or are wheeled into the stall

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Dealing with Bathing Problems

The client refuses the bath The client has dementia The client cannot tolerate the bathing procedure The client urinates or defecates Hardened secretions or stool on the client's body The client has an erection

The Back Massage

Relaxes muscles and promotes circulation Normally given after a bath or before bedtime and usually lasts 3-5 minutes Observe the skin before giving the massage Warm lotion between the hands or in water The prone position is best, but older adults or people with disabilities may find laying on their side more comfortable

Perineal Care

Involves cleaning the genital and anal areas to prevent infection, odors, and skin breakdown and promote comfort Performed at least once a day during the bath or whenever the area is soiled Follow standard and medical asepsis procedures Report and record any observed odors, redness, swelling, discharge, irritation, complaints of pain or discomfort, signs of incontinence, or presence of hemorrhoids

Oral Care

An essential part of maintaining overall physical health and should never be overlooked Oral hygiene (mouth care) keeps the mouth and teeth clean, prevents mouth odors, infections, and cavities, increases comfort, and makes food taste better

Periodontal Disease

A common problem in older adults

Bleeding Gums

Indicate the presence of illness or disease

Dry Mouth

A common result of illness, disease, or certain medications

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Bacteria in the Oral Cavity

Can grow and cause problems if oral hygiene is neglected

Oral Care Observations and Reporting

Inflammation of Tissues Around Teeth

More mouth care is needed, not less, when there is inflammation of the tissues around the teeth. Some medications and diseases can cause a white coating on the tongue, while others can cause redness and swelling of the mouth and tongue. Factors that can contribute to oral health issues include oxygen administration, smoking, low fluid intake, mouth breathing, and anxiety. Some medications can cause dry mouth. Oral diseases can lead to thickening of the carotid arteries, which increases the risk of heart disease.

Oral Care Procedures

Oral care is given to the client on awakening, after each meal, and at bedtime. Oral care should be provided at least every 2 hours. Always wear gloves during oral care. Gather the necessary supplies before providing oral care.

Observations During Oral Care

Dry, cracked, swollen, or blistered lips Bleeding, swelling, or redness of the gums Presence of sores or white patches on the oral mucosa or tongue Presence of food or foreign objects on the tongue and in the mouth Missing or loose teeth (loose teeth are a swallowing hazard) Rough, sharp, or chipped areas on dentures Foul breath Difficulty swallowing or speaking Complaints of pain or discomfort

Oral Hygiene Practices

Most clients can perform oral hygiene themselves, but in long-term care, the majority cannot perform them adequately. There is no consensus on the best way to brush teeth, but it is generally agreed that you should start at the gum line, hold the toothbrush at a 45-degree angle, and use short, back-and-forth strokes on the biting surfaces of the teeth.

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Normal Temperature Ranges

Mouth (oral temperature): 36°C - 37.5°C (average 37.4°C) Underarm (axillary temperature): 35.8°C - 38.0°C (average 36.5°C) According to age: Newborn: 30-60 breaths per minute Infant: 25-50 breaths per minute Toddler: 25-32 breaths per minute Child & Preadolescent: 20-30 breaths per minute Adolescent: 16-19 breaths per minute Adult: 12-20 breaths per minute

Normal Blood Pressure

Systolic Pressure: 120-160 mmHg

Care Planning and Nursing Process

Assessment

The care planning process, also called the 'nursing diagnosis,' is a plan to deliver care to clients. Assessment involves the evaluation of information collected about the client through observation, reflection, and communication. In some facilities, a team leader evaluates the emotional, spiritual, social, and intellectual health of a client. Only a nurse or physician can perform a physical assessment of a client. The team leader (nurse, social worker, or caseworker) gathers as much information as possible. Once the assessment is completed, the team members, including the client and the client's family, gather to set goals and meet the needs of the client.

Nursing Diagnosis

Using the information from the assessment, the nurse makes a nursing diagnosis. A nursing diagnosis is a statement describing a health problem that is treated by nursing measures. Nursing diagnoses consider the whole client, and only a nurse can make them. Examples of nursing diagnoses include low self-esteem, social isolation, or spiritual distress. Most Canadian nurses use nursing diagnoses from the list established by the North American Nursing Diagnosis Association (NANDA) or similar lists.

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