LOS ANGELES HARBOR COLLEGE - NURSING 339



LOS ANGELES HARBOR COLLEGE

Associate Degree Registered Nursing Program

NURSING 339: NURSING PROCESS AND PRACTICE IN THE CARE OF THE GERONTOLOGIC PATIENT

UNIT V

NURSING CARE OF PHYSIOLOGIC AND PSYCHOLOGIC DISORDERS

Description: This unit discusses age-related physiological and psychosocial changes and common health conditions/disorders experienced by older adult patients. Clinical experiences encompass competencies from first and second semesters, as well as N333, N335, and N339, Units I-IV. Students will apply Roy’s Adaptation Model, and the Nursing Process, in a variety of institutional and non-institutional community settings providing care to the elderly population.

Estimated Time of Achievement: Introduction of concepts during week 3 and 4 with mastery of theory and clinical performance objectives in 4.5 weeks.

Objectives Course Content Learning Activities

|After appropriate study of the assigned resources and clinical |Discussion of the normal physiological changes and function of |Resources: |

|experiences, the third semester nursing student will demonstrate |the integumentary – skin. | |

|applicable communication skills, critical thinking (problem solving), and| |Readings: |

|therapeutic nursing interventions to coordinate elements for developing |Various conditions discussed, e.g.: |Tablowski, Patricia A. (2014). Gerontological Nursing |

|therapeutic relationships and performing comprehensive psychosocial and |Senile purpura |3rd edition, Chapters 12-24. |

|physiological assessments, by: |Basal cell carcinoma | |

|1. Conducting comprehensive gerontologic assessment for elderly patient |Squamous cell carcinoma |Clinical Practice: |

|describing |Senile pruritus |In long term care setting |

|environmental factors and age-related changes that affect the assessment |Malignant melanoma |In home setting |

|process. | |In community settings (senior day cares and centers) |

|2. Demonstrating communication techniques for obtaining data from |Nursing interventions and educational opportunities for the |In Assisted Living setting |

|elements of the health history including the patient, family, and |older adult population. | |

|occupational profiles. | | |

|Demonstrating knowledge and skills for |Hair and nail changed with aging. | |

|conducting a Head-to-Toe physical | | |

|assessment by: |Review of pressure ulcers and the necessity for prevention. | |

|Calculating time needed and modifications required for age-related |Management of skin tears. | |

|variables that impact the assessment process including sensory deficits, | |Internet Resources: |

|neurological changes, |Knowledge-based decision making. |Alzheimer’s Association |

|and cognitive impairments. | |American Cancer Society |

|Differentiating adaptive age-related changes from pathophysiological |Multiple factors that contribute to poor oral hygiene – mouth &|American Foundation for the Blind |

|disease states. |oral cavity |Deafness Research Foundation |

|Interpreting assessment findings indicative of commonly occurring | |National Heart, Lung, and Blood Institute (blood pressure|

|age-related disorders/conditions/diseases for older adults, for example: |Normal changes related to aging – mouth and oral cavity. |information) nhlbi. |

|Pneumonia | |National Parkinson Foundation |

|Osteoporosis (content from 2nd Semester) |Nursing assessment of oral problems. |National Institute on Aging nia. |

|Restless Leg Syndrome | |National Center for Health Statistics nchs |

|Rheumatoid Arthritis (content from 2nd Semester) |Common oral diseases and conditions. |Patient education health handouts |

|Osteoarthritis (content from 2nd Semester) | | |

|Urinary Tract Infection (content from 1st Semester) |Barriers to good oral care. |Evaluation: |

|Incontinence (content from 1st Semester) | |1. Content tested on a 50 point |

|Benign Prostatic Hypertrophy (content from 1st Semester) |Sensory function, normal physiological changes, common |cumulative final examination. |

|Interpret disorders affecting sensory function. |problems, nursing assessment & interventions, and goals: |2. Clinical competencies are |

|- Interpret disorder affecting sensory function |Review of the five senses |performed by students in clinical areas as part of |

|Cataracts |Vision |patient care, during the 4.5 weeks of the course and in |

|Glaucoma |Taste |all subsequent courses. |

|Macular Degeneration |Smell | |

|Retinal detachment |Hearing | |

|Dry Eye Syndrome | | |

|Hearing loss |Identification and prevention of accidental deaths in the older| |

|- Interpret findings indicative of neurological and mental health |adult population. | |

|disorders | | |

|Alzheimer’s |Normal changes of aging in the cardiovascular system. | |

|Anxiety Disorders |Nursing assessment & intervention | |

|Loneliness and social isolation |Presentation of symptoms in older adults vs. younger adults | |

|Aggressive behaviors |“Other” causes of chest pain | |

|Depression |JNC VII report for assessment of | |

|4. Choosing appropriate nursing diagnoses based on assessment findings. |HTN | |

|Planning, implementing, and evaluating nursing interventions for |Nursing Diagnoses for cardiovascular problems | |

|physiological |Role of nursing | |

|disease states. |Hypotension | |

|6. Planning, implementing, and evaluating nursing interventions for age |Medications with hypotensive effects | |

|related physiological and psychosocial changes to maintain optimal |Hyperlipidemia | |

|functional ability. |Congestive Heart Failure | |

|7. Documenting assessment, intervention(s), and evaluative findings |Atrial fibrillation | |

|utilizing the nursing process format and school and agency forms. |Nursing interventions for the promotion of cardiac health | |

|8. Demonstrating a first level assessment one or more gerontologic | | |

|patient(s) in the community setting to identify adaptive and ineffective |Shingles and the shingles vaccine. | |

|behaviors demonstrating patient’s need in the physiological and | | |

|psychosocial modes by collecting a data base using active listening, |Herpes Zoster | |

|communication, and interviewing skills to identify alterations by: | | |

|Conducting a psychosocial assessment utilizing previous learned methods |Normal changes of aging in the respiratory system. | |

|to assess adaptive and ineffective behaviors in psychosocial modes by: |Nursing assessment & intervention | |

|Assessing cognitive ability using a mental status examination format. |Presentation of symptoms in older adults vs. younger adults | |

|Assessing psychosocial needs by noting nonverbal responses to care, |Relationship between airway inflammation, airway | |

|responses to disease and discomfort, coping mechanisms, ability to |hyperresponsiveness, airway obstruction, and asthma | |

|perform ADLs, self-care and usual roles. |Methods to quit smoking and resources available | |

|Communicating with patient to determine losses incurred by aging, |Additional measures to promote health | |

|illness, disability, long-term care, and role changes. |Pneumonia | |

|Focusing on patient’s feelings, strengths, and concerns. |Education for older patients with pneumonia | |

|Noting presence/absence of significant other, support systems, primary |Nursing diagnoses for respiratory | |

|care giver. |problems | |

|Conducting a physical assessment to identify adaptive and ineffective |SARS | |

|behaviors in the physiologic modes by: |COPD | |

|Measuring vital signs and oxygenation status using inspection, palpation,|Lung Cancer | |

|and auscultation. |Respiratory infections | |

|Inspecting color and integrity of skin and mucous membrane, observing for| | |

|thoracic deformities, breathing pattern and effort, amount and color of |Recommended vaccination schedule. | |

|secretions, pulsations, and venous distention. | | |

|Palpating skin temperature and moistness, noting lung expansion and chest|How to read a PPD, as it applies to the older adult. | |

|vibrations, presence and strength of pulses, rate of capillary refill, | | |

|and intactness of sensation and motor function. |Normal changes of aging in the genitourinary system – male and | |

|Auscultation lung, heart, and bowel sounds. |female. | |

|Inspecting abdomen for symmetry, distention, and pulsations, and |Nursing assessment & intervention | |

|palpating for firmness and tenderness. |Presentation of symptoms in older adults vs. younger adults | |

|Assessing abilities to perform ADLs, be mobile, perceive sensation and |Urinary tract infections | |

|temperature |Renal failure | |

|Analyzing data to identify adaptive/ ineffective behaviors in relation to|Prostate cancer | |

|psychosocial and physiologic needs by: |Cervical cancer | |

|Analyzing oxygenation behaviors i.e., cardiovascular: hypertension, |Uterine or endometrial cancer | |

|orthostatic hypotension, and stasis ulcer. Analyzing respiratory | | |

|behaviors, i.e., rate, DOE, dyspnea, oxygen saturation, crackles, |Normal changes of aging in the musculoskeletal system. | |

|fatigue, wheezes, mucus production, cough. |Nursing assessment & intervention | |

|Categorizing and analyzing fluid and electrolyte behaviors, i.e., edema, |Presentation of symptoms in older adults vs. younger adults | |

|dehydration, hypo/hyper kalemia, calcemia, natremia, sudden weight |Restless leg syndrome | |

|gains/loss. |Osteoporosis | |

|Analyzing nutrition behaviors, i.e., dental: loss of teeth, dentures or |Paget’s Disease | |

|poorly fitting dentures; dysphasia, and weight loss/gain. |Osteoarthritis | |

|Analyzing elimination behaviors, i.e., gastrointestinal: dysphasia, |Rheumatoid arthritis | |

|heartburn, flatus, hemorrhoids, n/v, ascites, constipation, impaction; | | |

|Genitourinary: UTI, nocturia, retention, incontinence |Falls and the older person: | |

|(stress/overflow/urge/functional). |Hip fractures | |

|Analyzing sexual behaviors, i.e., dyspareunia, vaginal dryness/bleeding/ |Nursing assessment and intervention | |

|infections, impotence. |Prevention | |

|Analyzing sleep and activity behaviors, i.e., musculoskeletal: muscle | | |

|cramping/claudication, foot pain, muscle strain, immobility, gait |Normal changes of aging in the endocrine system. | |

|changes; sleep disturbances: insomnia, hypersomnia, early wakening. |Nursing assessment & intervention | |

|Analyzing neurological behaviors, i.e., central neurological: organic, |Presentation of symptoms in older adults vs. younger adults | |

|dizziness, syncope, aphasia, altered mental status; cognitive impairment:|Thyroid – hyper and hypo | |

|defining delirium, dementia, Alzheimer’s disease. |Grave’s disease | |

|Analyzing behaviors that occur in cognitive impaired patients: |Diabetes: | |

|wandering, “sundowning”. |polypharmacy | |

|Analyzing drug toxicity/substance abuse behaviors. |depression | |

|Analyzing central neurological behaviors: functional, depression and |cognitive impairment | |

|anxiety behaviors. |urinary incontinence | |

|Analyzing common ineffective behaviors that interfere with or threaten |injurious falls | |

|vision: need for/use of visual aids. |pain | |

|Analyze cataracts, macular degeneration, glaucoma, and retinal detachment| | |

|Behaviors. |Normal changes of aging in the gastrointestinal system. | |

|Analyzing ineffective behaviors of hearing: need/use/fit of hearing |Nursing assessment & intervention | |

|aids. |Presentation of symptoms in older adults vs. younger adults | |

|Analyzing ineffective hormonal behaviors: hypo/hyperthyroidism, |Dysphagia | |

|hyperglycemia. |GERD | |

|Analyzing integumentary behaviors: lesions, neoplasms (benign and |Gastritis | |

|malignant), ulcerations, and decubiti. |Cancer | |

|Analyzing role function: growth and developmental tasks. |Fecal incontinence | |

|Analyzing self-concept: coping. |Constipation | |

|Analyzing interdependence behaviors: dependent/independent behaviors,|Peptic/duodenal ulcer disease | |

|ineffective behaviors in patient, family, and/or caregiver. |Diarrhea | |

|Performing a second level assessment of physiologic and psychosocial |Benign and malignant tumors | |

|needs by |Hemorrhoids/rectal bleeding | |

|identifying stimuli for adaptive and ineffective behaviors for the |Liver disease or cancer | |

|following modes: |Pancreatitis | |

|Oxygenation: loss of elasticity of vessels and heart muscle. |Specific nursing diagnoses | |

|Respiratory: decreased blood flow to pulmonary circulation/decreased | | |

|diffusion/pulmonary elasticity, muscle atrophy of pharynx and larynx, |Normal changes of aging in the hematologic system. | |

|shallow breathing, and air resistance. |Nursing assessment & intervention | |

|Fluid and electrolytes: decreased ability of kidneys to concentrate |Presentation of symptoms in older adults vs. younger adults | |

|urine/regulate excretion: heart failure, diuretics, dehydration. |Nursing diagnoses | |

|Nutrition: loss of teeth/ill-fitting dentures, weak mastication, |Anemia | |

|difficulty swallowing, malabsorption of nutrients and vitamins/minerals, |Chronic myeloproliferative disorders | |

|anorexia, decreased digestive enzymes, inability to prepare meals, lack |Multiple myeloma | |

|of money/transportation to market. |Nursing assessment of older patients with hematologic | |

|Elimination: reduced renal function, loss of bladder tone, reduced neuro|abnormalities | |

|transmission, reduced esophageal/gastric/intestinal motility, decreased |Preventive approaches for DVT | |

|gastric/intestinal juices/enzymes, decreased abdominal muscle strength, |Anticoagulation | |

|decreased ability to excrete drugs. |Nursing interventions to promote self-care | |

|Activity and Rest: decreased strength, osteoporosis, ostoarthritis, loss| | |

|of muscle mass/strength, decreased stamina, shortening of trunk, limited |Normal changes of aging in the nervous system. | |

|ROM, stage IV sleep reduced/frequency of wakening, sleep deprivation, |Nursing assessment & intervention | |

|bedrest, limited mobility, anxiety, depression. |Presentation of symptoms in older adults vs. younger adults | |

|Sensory regulation: voluntary or automatic reflexes slower, decreased |Nursing diagnoses | |

|ability to respond to multi-stimuli, loss of neurons, peripheral vision |Parkinson’s | |

|and lens accommodation decreased, lens opacity, hearing impairment (high |TIA’s | |

|frequency sounds), atrophy of taste buds, decreased sense of smell, |CVA | |

|increased threshold for light touch and pain, decreased estrogen/ |Dementia | |

|testosterone production, loss of skin elasticity/mass/moisture, slow |Alzheimer’s Disease – impaired cognitive processes | |

|healing of wounds, decreased ability to metabolize drugs, sensory |Mood disorders | |

|overload or deprivation, action of medications. |Anxiety | |

|Role: response to age, sex, education, training, job status (working/ |Promoting mental health | |

|retired), abilities or inabilities to meet role tasks. | | |

|Self-concept: responses to age, degree of physical ability, previous |Viewing and discussion of a DVD/video entitled “Louie, Louie – | |

|learned coping mechanisms, religious beliefs, cultural orientation, |a portrait in Parkinson’s” by Cynthia Salzman Mondell, | |

|socioeconomic status, joys, feeling of loss, grieving, anxiety, anger, | | |

|depression, shame, guilt, invasion of spaces or loss of territoriality. |The film addresses the struggle it is to live with the disease | |

|Interdependence: availability of support systems/significant other, |and the challenges for both the individual and the family faced| |

|losses, values, strengths, adaptation to disabilities feelings of |in providing care and making end of life decisions. Hopefully,| |

|isolation, helplessness, powerlessness, insecurity, hopelessness, life |this film will allow for more discussion and helping patients | |

|experiences and previous experience with the health care team. |and families in finding their own answers and solutions in | |

|Differentiate factors that put the patient “at risk”. |dealing with a very difficult disease. | |

|Differentiate iatrogenic factors that contribute to ineffective | | |

|behaviors. |Normal changes of aging in the immune system. | |

|Differentiate immediate factors that contribute to ineffective behaviors.|Nursing assessment & intervention | |

|Choose nursing diagnosis that applies to the assessment findings for the |Presentation of symptoms in older adults vs. younger adults | |

|gerontologic patient for physiological, self-concept, role function, and |Nursing diagnoses | |

|interdependence modes. |Factors impacting the immune response | |

|12. Determine patient goals specifying the following: |HIV | |

|Expected change in the stated diagnosis. |Rheumatic disorders | |

|Expected patient outcome behaviors. |Tuberculosis | |

|Critical time for achieving the outcome behaviors and goals. |Health behaviors to improve the immune system | |

|13. Demonstrate nursing interventions to alter stimuli and achieve | | |

|patient goals: |Chronic disease and frailty – multisystem problems – frail | |

|Assess patient, document and communicate behaviors and diagnostic |elderly | |

|findings prior to and after implemented actions. |Cancer | |

|Assess patient for risk factors, document and communicate findings |Heart disease | |

|Collaborate with family, primary care giver, and other health care |Alzheimer’s Disease | |

|providers. |Musculoskeletal problems | |

|Implement patient teaching: |Diabetes Mellitus | |

|Instruct patient, family, primary care giver as to reasons for actions/ |Hospitalized nursing home residents | |

|interventions. |Hospitalization statistics for older persons | |

|Reinforce information given by other health care providers. |Frailty unplanned | |

|Develop teaching plan, content and handouts on common elderly issue or |Frail elder | |

|disease and present at senior care center. |Three pathways leading to frailty | |

|14. Evaluate effectiveness of interventions in achieving patient | | |

|outcomes. |Prevention education | |

|Assess patient behaviors after interventions. | | |

|Compare post intervention patient behaviors to those initially assessed. |Palliative care | |

|Determine if goals were met. | | |

|Revise care plan and implement same or alternate interventions as |Ethics committees | |

|indicated. | | |

|Effectively function as a member of the health care team. | | |

|Effectively collaborate with members of interdisciplinary team. | | |

|Maintain a safe environment to prevent physical and emotional jeopardy. | | |

|Communicate and document assessments, actions, and evaluations. | | |

|Act professionally, legally, and ethically always. | | |

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