Elderly, Death Dying

Gerontology Geriatrics

Good Aging

Vision Changes Decreased • • • • • •

visual acuity and visual fields lens accommodation dark adaptation and depth perception color discrimination (blues and greens) Tears lens elasticity (Presbyopia)

Assessment Findings • Arcus senilis - white circle around the iris • Cataracts - clouding of the normally clear lens • Macular degeneration - loss of central vision • Glaucoma - increased intraocular pressure • Smaller pupil size • Dry, red eyes • Vitreous floaters lightning flashes

Nursing Considerations • Place objects in the visual field • Use large lettering to label meds • Allow more time to focus / adjust to the envir. • Avoid glare, Use night-lights • Use red and yellow to stimulate vision. • Mark the edges of stairs and curbs • Encourage yrly eye exams • Encourage use of isotonic eyedrops as needed. • Encourage use of low vision aids

Hearing Loss • Sensorineural - loss of high-tone perception • Conduction deafness muffled sounds, Cerumen impaction, reversible. • Hearing loss increases with age and is greater in men. • Decreased speech discrimination, esp with background noise.

• Increased speech volume • Turning of head toward speaker • Requests of a speaker to repeat • Inappropriate answers (cognitively intact) • become frustrated, angry, and depressed • Lack of response to a loud noise

Nursing Considerations • Hearing test, evaluate ear canals for Cerumen impaction • Face the person directly so he can lip read. Touch the person to get his attention before talking. • Use gestures and objects to help with verbal communication. • Speak into the person's “good ear” slowly and clearly. Allow the person more time to answer your questions. • Suggest amplifiers on telephones and alarms.

Smell • • • •

Smell receptors decreases due to sinus dz Discrimination of fruity odors persist the longest. Inability to notice unpleasant odors Decreased appetite

Nursing Considerations – At mealtime, name food items – Suggest use of stronger spices and flavorings to stimulate smell.

Taste • Taste buds half gone by 60. 1/6 remain by 80 • Taste buds are lost from the front to the back (ie, sweet and salty first then bitter and sour). Assessment Findings • food has no taste. Uses excessive sugar / salt. Inability to ID foods. No enjoyment in eating • Decrease in appetite and weight loss

Nursing Considerations • Serve food attractively, and separate different types of foods. • Vary the texture of foods. • Encourage good oral hygiene. • Season food.

Kinesthetic Sense • Change in balance. less able to a fall from • Shorter step length, less leg lift, a wider base, and tendency to lean forward. • Alterations in posture, ability to transfer, and gait • Complaint of dizziness

Nursing Considerations • • • •

Position items within reach. Give person more time to move. Take precautions to prevent falls. Suggest physical therapy with balance training after periods of prolonged immobility.

Cardiovascular • Thick rigid valves and blood vessels • Max HR / aerobic capacity decrease. Once elevated, takes longer to return to baseline. • Slower response to stress • Decline in maximum oxygen consumption. • Normal BP 120/80 mm Hg and below • BP 121 to 129/81 to 89 mm Hg pre HTN • BP 130 to 159/90 to 109 mm Hg grade 1 HTN • BP 160/110 mm Hg and above grade 2 HTN

Nursing Considerations • Encourage – regular BP eval and lifestyle modifications and medication adherence – longer cool-down period after exercise – regular aerobic exercise: walking, biking, or swimming for 20 minutes at least three times per week.

Pulmonary • Respiratory muscles become weaker, Decreased elastic recoil of the chest wall • Total lung capacity unchanged but residual volume and functional residual capacity increase. • Partial pressure of oxygen decreases due to ventilation perfusion mismatches • Decreased mucus, foreign body clearance • Prolonged cough & inability to raise secretions therefore increased frequency of infections

Nursing Considerations • C&DB post surgery • Avoid crowds during cold and flu season, wash hands frequently, report early signs of infection. • Avoid smoking and exposure to secondhand smoke.

Immunologic • Decline in the immune system (decr T-cell & B-cell function Assessment Findings • More frequent infections • Increased incidence of many types of cancer • Teach people that they are at increased risk of infection, cancer, and autoimmune disease • Routine follow-up and screening are essential.

Neurologic Decreased • Neurons / no major change in neurotransmitter levels. • Brain size / no cognitive impairment. • muscle tone, motor speed, and nerve conduction velocity. • gait speed , step length, stride length, and arm swing. • position and vibration sense, diminished reflexes

Nursing Considerations • Teach fall prevention techniques • Environmental safety – – – –

nonslip surfaces securely fastened handrails sufficient light, glare-free lights avoid of low-lying objects, chairs of the proper height with armrests – skidproof strips or mats in the tub or shower – toilet and tub grab bars – elevated toilet seats.

Musculoskeletal • Declining muscle mass and endurance • Decreased bone density (more in women) • Decreased thickness and resiliency of cartilage

Assessment Findings – Muscle atrophy, Increased incidence of fx – Complaint of joint stiffness in absence of arthritis – Decrease bone density

Nursing Considerations • Encourage regular exercise • 20 min of continuous aerobic exercise, may need stress test before starting • Encouraged to exercise at a set time, to relieve pain before exercising • Promote calcium and vitamin D intake and decrease alcohol and nicotine use

Endocrine • Decreased reaction to stress (pituitary gld) • Holds fluid - elevated vasopressin (antidiuretic hormone) • Normal insulin secretion but decr secretion in response to a glucose load

Nursing Considerations – Encourage routine screening of blood glucose ( both fasting and postprandial). – Provide dietary education about a wellbalanced diet.

Reproductive

• decreases ovary size / hormone prod • uterine involution, vaginal atrophy, and loss of breast mass. • Risk cystocele, rectocele, and uterine prolapse. • Decr testosterone prod / secretion • Vaginal dryness, painful intercourse • Atrophic vaginitis, Urinary incontinence

Nursing Considerations • Suggest the use of additional lubrication during sexual intercourse. • Advise sexually active older men that spermatogenesis may continue into advanced age. • Address poss hormone replacement therapy for symptomatic relief related to menopause.

Renal and Body Composition • Incr body fat and decr lean muscle mass • Decr renal function, (GFR / creat clear) • Decr total body creatinine/ serum creatinine unchanged • Increased incidence of anemia • Be aware that although creatinine level may be within normal range, creatinine clearance may be decreased.

Skin • Thin, fragile, dry skin, fewer melanocytes, decreased elasticity , Less temp control • Reduced sensory input, impaired cell-related immune response. • Avoid excessive use of soap, use lubrication • Avoid direct application of extreme hot or cold to skin because damage may occur without feeling it. • Encourage use of sunscreen during all outdoor activities.

Treatment for xerosis – Drink 2,000 mL of liquid daily. – Total body immersion in warm water (90° to 105° F for 10 minutes. – Use of nonperfumed soap without hexachlorophene. – Apply emollients with alpha-hydroxy acids after bathing and at bedtime.

Hematopoietic • Number of stem cells are unchanged • Decr bone marrow cellularity and activity • Nursing Considerations – Anemia and granulocytopenia are WNL – No need to take oral iron unless decrease in iron levels. – Encourage oral B12 and folate replacement to manage associated anemias.

Altered Presentation of Disease • Manifestations of illness are less dramatic • Classic indicators of disease are usually absent or disorders present atypically • New symptoms are attributed to aging or existing conditions • minimize symptoms because of fears of hospitalization or health care costs. • Pay attention if the older adult presents with an acute change in cognition, behavior, or function.

Functional And Psychosocial Status

Altered Mental Status Delirium • abrupt in onset • due to an underlying medical condition • reversible with treatment of the underlying cause • Acutre behavioral change

Dementia • gradual onset • Behavior is usually stable, • disorientation occurs late

Depression • Insomnia, weight loss & anorexia, constipation • Preoccupation with past life events • Decrease in concentration, memory, and decision making (dementia syndrome) • Musculoskeletal aches and pains, chest pain • Suicide high in older white men

Nursing and Patient • Find Positives – Encourage participation in meaningful activities. – Compliment the person. – Help the person develop a sense of mastery. – Encourage reminiscence of meaningful past events.

• For behavioral problems - aromatherapy, music therapy, pet therapy, or massage.

Motivation in Elderly Patients • • • •

Base goals on past experiences Make short goals daily Mastery but do not cause discomfort Make sure the environment is right

Health Concerns Preventive measures • • • •

Heart disease Cancer Stroke Smoking, Alcohol abuse • Nutrition • Dental problems

• • • • • •

Exercise Arthritis Falls Sensory impairment Pain Medication use

Psychosocial Changes and Health Concerns • • • •

Reality orientation Reminiscence Body image Acute care environment • Restorative care environment

• • • •

Retirement Social isolation Sexuality Housing and environment • Death

Loss, Grieving, and Death Terminally Ill Patients Video

Thanatology Study of death The description of study of the phenomena of death, and of psychological mechanisms for coping with death

NC_termillpatients.mov

Death and Dying • Assisting the patient to “Live well” and “Die well” What does this mean to you?

Common Fears Of The Dying Patient • • • •

Fear of Loneliness or Fear of Sorrow Fear of the unknown Loss of self concept and body integrity Fear of Regression or Fear of Loss of Self Control • Fear of Suffering and Pain Kübler-Ross Stages of Grieving • Denial, Anger, Bargaining, Depression, Acceptance

Experienced before loss occurs. Can be actual or perceived

ANTICIPATORY -

ACTUAL -

TYPES

Recognized by others

SITUATIONAL

OF

Loss of job, death of child

LOSS •DEVELOP MENTAL Departure of children from home

PERCEIVED Experienced by one person but cannot be verified by others

Sources of Loss •

Loss of an aspect of oneself

•

Loss of an object external to oneself

•

Separation from an accustomed environment

•

Loss of a loved one or valued person

•

Children experience the same emotions of grief as adults.

NC_termillpatients.mov

Age, Gender and culture Significance of the loss or cause of death

Factors Affecting Grief

Spiritual beliefs, support system Socioeconomic status

Explore and respect values

Interventions

Teach what to expect in the grief process Encourage expression and sharing of grief Encourage the client to resume activities

Factors Affecting Grief Response • Circumstances concerning death – Sudden, unexpected death – Lengthy illness resulting in death – Loss of a child – Perception that the death was preventable – Unsteady relationship with deceased – Mental illness of survivor – Lack of social support – Infant, Toddler, Preschool, School Aged, Adolescent

Verbalization of the loss Crying Sleep disturbance Loss of appetite Difficulty concentrating

Complicated Grieving

Normal Manifestations

Extended time of denial Depression Severe physiologic symptoms Suicidal thoughts

Nursing Strategies Appropriate For Grieving Persons • • • • •

Open ended statements and let Pt sets the pace Accept any grief reaction, you may be target of anger Remove barriers, Avoid giving advice Allow patient to talk or express signs of hope Support hope by helping focus

Assist Family to Grieve • • • • • • •

Explain procedures and equipment Prepare them about the dying process Involve family and arrange for visitors Encourage communication Provide daily updates Resources Do not deliver bad news when only one family member is present

Effects of Culture on Beliefs About Death

• Influence how one reacts to loss, grief, and death • Governs expressions of grief that is acceptable by the family • Identifies spiritual beliefs, specific rites, rituals, and practices that provide comfort • Nurses need to be in tune with patients’ spiritual needs • Becoming familiar with cultural views will help

Cultural Considerations Related to End-of-Life Issues • Chinese—to discuss death is taboo, considered bad luck and evil • Muslim—illness is a result of sin and death is part of life as destined by God • Orthodox Jews—do not leave the dying person alone; have “minyan” praying at the bedside • Hindu—may refuse food and pain medication because of belief in transmigration; head will face east with a lamp near the head; family will chant (mantra) and pray; they may spread incense and apply ash to the client’s forehead • Catholic—priest will anoint the client and give Holy Communion

Communicating Truthfully about Terminal Illness • Patient has a right to know and the time frame • The physician will tell the client first • Nurse assesses what the patient/family have been told • Choices of Care Setting • Patient or family have the right to choose where to care is to be provided • Hospital, Home/Hospice

Helping Clients Die with Dignity • Thorough pain control • Maintain independence • Prevent isolation • Spiritual comfort • Support the family

Assisting Families or Caregivers of Dying Clients • Support those who feel unable to care for or be with the dying • Show an appropriate waiting area if they wish to remain nearby • May be therapeutic for the family to verbally give permission to the client to “let go” when ready

Essential Goals of Palliative Care 1. Prevention, relief, reduction, or soothing of symptoms 2. Allow clients to make informed choices 3. Achieve better relief of symptoms 4. Allow clients the opportunity to work on end of life issues 5. Allow client to experience a “good death”

Hospice • Multidisciplinary, family centered program of care designed to assist the terminally ill through the phases of dying • Physician, RN, LPN, aide, and chaplain are available to assist the client and family • Provide many services, such as respite care, medical equipment, medication • Services based on need, not ability to pay

Signs/Symptoms of Approaching Death • Motion and sensation is gradually lost • Increase in temp, cold clammy skin • Pulse-irregular, and rapid, decrease BP • Respirations-strenuous, irregular, Cheyne stokes, “Death rattle” • Jaw and Facial muscles relax • Most positive sign of death=absence of brain waves (Need two MDs to sign off)

World Medical Assembly Guidelines for Death • No response to external stimuli • No muscular movement, esp during breathing • No reflexes • Flat encephalogram • In instances of artificial support, absence of brain waves for at least 24 hours

Cerebral Death •

Cerebral cortex is irreversibly destroyed

•

Permanent loss of cerebral and brainstem function – Absence of responsiveness to external stimuli, cephalic reflexes, Apnea

•

Isoelectric EEG for at least 30 minutes in the absence of hypothermia and poisoning by CNS depressants

•

Physical Changes of Death Rigor mortis—stiffening of the body Algor mortis—loss of skin elasticity Livor mortis—purple discoloration of skin

Post-mortem—after death • The Uniform Determination of Death Act (UDDA)— defines death as “irreversible cessation of circulatory and respiratory functions or irreversible cessation of all functions of the brain, including the brainstem” • Post-mortem care – must be done soon after death because of the changes the body undergoes – DNR—do not resuscitate – Omnibus Budget Reconciliation Act (OBRA) of 1986 – Autopsy—postmortem exam to determine the exact cause of death – Cultural considerations

Organ Donation 1. Client must be on life-support to support vital organs 2. Family must understand that client is braindead 3. No age limit although parents must consent when client is under 18 years old 4. Indicate on drivers license request to be organ donor, although family makes the final decision

Care of the Body After Death • • • • •

Check orders for special requests Remove equipment and supplies Change soiled linens and cleanse patient Use room deodorizer Place patient in supine position, with small pillow under head • Insert dentures • Remove valuables and give to family • Stay with family, if requested

Continued… •

What can be donated? – Organs—heart, kidneys, pancreas, lungs, liver, intestines – Tissue—cornea, skin, heart valves, connective tissue – Bone marrow Organ donation does not affect the appearance of the body; an open casket is still possible

After Client Dies • Encourage the family to view the body • May wish to clip a lock of hair as a remembrance • Children should be included in the events surrounding the death if they wish

Nursing Interventions • Provide private place for family discussion • Be sure that the decision is made by the appropriate person • Contact local donor registry • Inform family that body will be cared for • Be sure family understands that there is no cost for organ donation

After The Family Leaves • • • • • •

Leave wrist ID tag on Apply additional identification tags Wrap the body in a shroud Apply ID to the outside of the shroud Take the body to the morgue Or arrange to have a mortician pick it up from the client’s room • Handle the deceased with dignity

Autopsy or Organ Donation • Autopsy - to determine cause of death, coroners case • For tissue and organ removal: – Keep CV system going, Call donor bank representative – Must be agreed on by all family members, patient decision before death

• Legally person is dead when brain waves cease – This definition allows for harvesting of organs and tissue for donation – Vital organs are: heart, liver, kidney, lung, pancreas – Non-vital organs are: eye corneas, long bones, middle ear bones, and skin

Autopsy • External Procedure – Body is brought to the morgue and photographed and x-rayed as indicated – Body is cleaned, weighed, and placed on autopsy table – The body is placed face up on the table, and a body block is placed under the patient's back. – A general description of the body is made and all identifying features are noted

Continued… • Internal Examination – A large, deep, Y-shaped incision that is made from shoulder to shoulder meeting at the breast bone and extends all the way down to the pubic bone. – When a woman is being examined, the Yincision is curved around the bottom of the breasts before meeting at the breast bone. – The next step is to peel back the skin, muscle, and soft tissue

Continued…

Continued… – The chest flap is pulled up over the face, exposing the ribcage and neck muscles. – Two cuts are made on each side of the ribcage, and then the ribcage is pulled from the skeleton after dissecting the tissue behind it with a scalpel. – A series of cuts are made and organs are removed and weighed

Continued…

Continued…

Continued…

Autopsy Room

Post-Mortem Care • Always follow agency policy and procedure • Ensure that correct identification is on the body • Remove foley catheters, ET tubes, oxygen, and peripheral IV’s • Reinsert dentures if possible. If not, place them in cup to stay with body

Continued… • Position body in natural position, avoid placing one hand over the other • Place small pillow under head and elevate the head of the bed 10-15 degrees • Close eyes, unless contraindicated by client’s religious preference • Shave men unless family requests otherwise

Good Aging