ROLE OF NURSE FOR CARE OF ELDERLY: AMBULATION, NUTRITIONAL, COMMUNICATION,

PSYCHOSOCIAL AND SPIRITUAL

INTRODUCTION

The elderly population is growing worldwide. As the age advances, there is decline in the physical function and the
person becomes susceptible to both the acute and chronic health problems. It makes them frequent user of health
care services. Many patients present with multiple co-morbid conditions which may be exacerbated by the confusion
and anxiety of hospitalization. Elderly patients have age specific, complex and multifaceted needs. They are affected
in unique ways by the combined effects of the ageing process, the disease process and the environment, which
challenge their sense of self and influence their perception of quality of life. The elderly need nursing care which should
be provided by a nurse who is knowledgeable, skilled, vigilant, sensitive, proactive, respectful and positively motivated
about caring for the older persons.

The main objectives of providing nursing care to the elderly are:

• To promote and maintain optimal level of health and function, detect health problems at an early stage;

• To prevent deterioration of an existing disease condition and

• To prevent further complications.

ASSESSMENT

Evaluation of the results of a comprehensive nursing assessment helps determine the service and placement needs
of older adults. The goal is to plan and implement actions that help older adults remain as functionally independent
as possible. Fulmer SPICES is an efficient and effective instrument for obtaining the information necessary to prevent
health alterations in the older adult patient. SPICES is an acronym for the common syndromes of the elderly
requiring nursing intervention:

SPICES EVIDENCE
Sleep disorders Yes/No

Problems with eating or feeding Yes/No

Incontinence Yes/No

Confusion Yes/No

Evidence of falls Yes/No

Skin breakdown Yes/No

ROLE OF NURSE IN AMBULATION

Elderly patients whose mobility has become limited due to aging requires a certain amount of assistance in his or her
daily routine. If it is not possible for someone in the family to be around the aged person the whole day long, full-time
nurse may be employed to assist the elderly person. This could be beneficial, especially if the elderly person requires
assistance in basic activities like walking, eating, bathing, dressing, etc.
  A safe environment allows the patient to move about as freely as possible and relieves the family of constant
worry about safety.
 To prevent falls and other injuries, all obvious hazards are removed. Nightlights are helpful.
 The patient’s intake of medications and food is monitored.
 Smoking is allowed only with supervision.
 A hazard-free environment allows the patient maximum independence and a sense of autonomy. Because of
a short attention span and forgetfulness, wandering behaviour can often be reduced by gently persuading or
distracting the patient.
 Combine hygienic activities with a favourite reinforce to enhance participation.
 Restraints are avoided because they may increase agitation. Doors leading from the house must be secured.
 Outside the home, all activities must be supervised to protect the patient, and the patient should wear an
identification bracelet or neck chain in case he or she becomes separated from the caregiver.
 The nurse should help the person remain functionally independent for as long as possible. One way to do this
is to simplify daily activities by organizing them into short, achievable steps so that the patient experiences a
sense of accomplishment.
 Frequently, an occupational therapist can suggest ways to simplify tasks or recommend adaptive equipment.
Direct patient supervision is sometimes necessary, but maintaining personal dignity and autonomy is
important. He or she is encouraged to make choices when appropriate and to participate in self-care activities
as much as possible.

Nursing diagnoses-

Self-care deficit related to increased forgetfulness secondary to disease progression.

Activity intolerance related to weakness and limited joint movement

Risk for fall/injury related to inappropriate judgement and wandering.

ROLE OF NURSE IN NUTRITION

As people age, their digestive system gradually starts weakening. Aged and elderly people especially, face this problem
wherein they start finding certain foods indigestible or difficult to digest. What one must realize is that their diet can
no longer be the same as it was say, twenty years ago. Their diet should now be modified accordingly such that it
remains a nutritious, balanced diet and yet, contains food stuffs that their system is able to accept, without causing
them any discomfort or problems. Often, the diets of elderly people need to be altered depending on their medicinal
prescriptions.

SCALES: Nutritional Assessment can be used to assess important nutritional indicators-

 Sadness or mood change

 Cholesterol, high
 Albumin, low
 Loss or gain of weight
 Eating problems (e.g. mechanical problems such as impaired swallowing, poor dentition)
 Shopping and food preparation problems

Nursing Diagnosis

Altered Nutrition: Less than body requirement related to disease progression, feeding self-care deficit, and potential
dysphasia.

 Mealtime can be a pleasant, social occasion or a time of upset and distress, so it should be kept simple and
calm, without confrontations.
  The patient will prefer familiar foods that look appetizing and taste good. To avoid the patient’s “playing” with
the food, one dish is offered at a time. Food is cut into small pieces to prevent choking.
 Liquids may be easier to swallow if they are converted to gelatin.
 Hot food and beverages are served warm, but the temperature of the foods should be checked to prevent
burns.
 When lack of coordination interferes with self-feeding, adaptive equipment is helpful. Some patients may do
well eating with their fingers. If this is the case, an apron or a smock, rather than a bib, is used to protect
clothing.
 As deficits progress, it may be necessary to feed the patient. Forgetfulness, disinterest, dental problems,
incoordination, overstimulation, and choking can all serve as barriers to good nutrition.

ROLE OF NURSE IN COMMUNICATION

Effective communication facilitates positive patient outcomes. When caring for senior patients, this might involve
providing for certain issues. Older patients may have multiple conditions, such as hearing loss, vision impairment,
dementia, or Alzheimer’s disease. When treating the elderly, it’s important not to make assumptions about patients’
abilities and to take time to understand the conditions and circumstances that are unique to each client.

Nursing diagnoses

Disturbed thought processes related to cerebral cortex degeneration

Disturbed sensory perception related to hearing loss, altered vision

 To promote the patient’s interpretation of messages, the nurse remains unhurried and reduces noises and
distractions.
 The nurse uses clear, easy-to-understand sentences to convey messages, because the patient frequently
forgets the meaning of words or has difficulty organizing and expressing thoughts.
 Facilitate use of hearing and visual aids
 For hearing impaired patients, speak under a good light, avoid covering mouth or face and avoid careless
expression that the patient may misinterpret
 Lists and simple written instructions can serve as reminders to the patient and are often helpful. Sometimes,
the patient can point to an object or use nonverbal language to communicate.
 Tactile stimuli, such as a hug or a hand pat, are usually interpreted as signs of affection, concern, and security.

ROLE OF NURSE IN PSYCHOSOCIAL AND SPIRITUAL NEEDS

Very old individuals living alone are often depressed; the risk factors include living in distance from family and low
satisfaction with living accommodation and finances. However, individuals may experience depression also in nursing
homes; the risk factors involve physical affections and limitations, loneliness and lack of social support, and so forth.
Several studies suggest that the exercise of spiritual activities can influence through positive emotions such as hope,
forgiveness, self-esteem and love which may be important for mental health.

It is determined that religion is an important dimension in the lives of the elderly. People with religious beliefs and
practices are better able to cope with stressful situations that lead to aging, enjoy better physical and mental health,
and live longer than non-practitioners.

 It is necessary for nurses to provide the elderly with the resources to meet their spiritual demands as they
consider it and that can range from small manifestations of help to great moments of meditation
 An approach is necessary that allows the nurses understand that any time of contact with the elderly is a
moment of care and is a transpersonal relationship. When nurses allow themselves to get to know their
patients, they allow them to create a connection that makes care a moment of real health help.
 Watch for any signs of mental, physical abuse or neglect.
  Patients should feel as though care providers understand and identify with their concerns. To communicate
this sentiment, staff members can relate how they would feel given similar circumstances when
communicating undesirable information. Such honest and open communication shows that care providers
recognize client difficulties and genuinely care about patient circumstances.

ROLE OF FORMAL AND NON-FORMAL CAREGIVERS

CAREGIVERS OF ELDERLY

Formal caregivers are those who are paid to give care, whereas informal caregivers are not paid to provide care. For
example, a nurse is a formal caregiver, and a family member is an informal caregiver

Planning for care and understanding the psychosocial issues confronting the older person must be accomplished within
the context of the family. If dependency needs occur, the spouse often assumes the role of primary caregiver. In the
absence of the surviving spouse, an adult child usually assumes caregiver responsibilities and may eventually need
help in providing care and support.

ROLE OF CAREGIVERS OF ELDERLY

ADVISER/CONSULTANT: The caregiver must learn how to talk and listen to their client’s feelings and give counselling
if the need arises. Acquainting the elder in the surroundings will diminish the feeling of insecurity.

TEACHER: Informs the patient on information pertaining to healthful practices of everyday life, assist with the
treatment to avoid further diseases or illnesses that may occur. Educates the aged on how to care for his personal
hygiene with or without the presence of a nurse or a caregiver

SPONSOR: Represents the patient on community services, plans, arranges, and explains the patient’s rights.

ORGANIZER/COORDINATOR: The caregiver is in direct contact with the patient and the whole health care team is
surrounding it that is why proper coordination in ensuring the total wellness of an elderly is the main focus.

RESPONSIBILITIES

Caregivers spend a substantial amount of time interacting with their care recipients, while providing care in a wide
range of activities. Nurses have a limited view of this interaction. Caregiving can last for a short period of postacute
care, especially after a hospitalization, to more than 40 years of ongoing care for a person with chronic care needs.

 Performs direct nursing measures and care activities like vital signs monitoring
 Maintains a safe, clean and healthful environment for the patient
 Care of the patients welfare socially, intellectually, spiritually, physically and emotionally
 Guides and assists the patient in their personal hygiene such as toileting, grooming, dressing and bathing.
Elders are unable to do it by themselves.
 Prepares meals prescribed and as instructed by the attending physician
 Bedside care early in the morning and afternoon care, sleep care and as needed care
 Medicine preparation and administration to ensure that proper and adequate medications are being
implemented
 Informs the elders when rehabilitation is needed such as physical therapy
 Performs errands for the elders. This is on a case to case basis.
 Provides assistance on house calls or attends to visit the physician on schedule

Care giving is really a hard job in that it takes an effective approach as to how a caregiver will manage the care of the
elderly which will provide for a more healthful and convenient way of living for the old ones. The best way to do is
learn, learn and learn and apply effectively what you have learned without you being affected. Caregivers must put
limitations on caring for the elderly while caring for themselves as well.

FURTHER ROLE OF A CAREGIVER

A formal caregiver for the elderly must be cautious not to become too close, but there are many other roles a caregiver
can give to their elderly patient. Giving emotional support can be very helpful and a very healthy support for the elderly
patient. Sometimes this can be hard because a caregiver must listen to the complaining by the patients. Many times
elderly patient will have problems with their family members, usually sons and daughters. The caregiver’s patient
might need someone to talk to, and the caregiver also has to be a good listener.

ROLE OF NURSE FOR CAREGIVERS OF ELDERLY

Recent surveys estimate there are 44 million caregivers over the age of 18 years (approximately one in every five
adults). Most caregivers are women who handle time-consuming and difficult tasks like personal care, but at least 40
percent of caregivers are men. These male caregivers are becoming more involved in complex tasks like managing
finances and arranging care, as well as direct assistance with more personal care. Nurses are likely to see many of
these caregivers, although many of them will not identify themselves as a caregiver.

In many cases, they are alone in this work. About two out of three older care recipients get help from only one unpaid
caregiver. In the last decade, the proportion of older persons with disabilities who rely solely on family care has
increased dramatically—nearly two-thirds of older adults who need help get no help from formal sources.

Regardless of the amount of responsibility and love an adult child exhibits toward dependent elderly parents, strains
do develop if care continues for a long period.

HAZARDS OF CAREGIVING

 Caregivers are hidden patients themselves, with serious adverse physical and mental health consequences
from their physically and emotionally demanding work as caregivers and reduced attention to their own health
and health care.
 Declines in physical health and premature death among caregivers in general have been reported. Elderly
spouses who experience stressful caregiving demands have a 63 percent higher mortality rate than their non-
caregiver age-peers.
 Researchers have reported that caregivers are at risk for fatigue and sleep disturbances, lower immune
functioning, altered response to influenza shots, slower wound healing, increased insulin levels and blood
pressure, altered lipid profiles, and higher risks for cardiovascular disease.
 With a high level of caregiving activities, the odds of the caregiver not getting rest, not having time to exercise,
and actually not recuperating from illness were also high. In addition, caregivers were more likely to forget to
take their prescriptions for their own chronic illnesses, which poses a threat to their overall health
 Caregivers who are employed report missed days, interruptions at work, leaves of absence, and reduced
productivity because of their caregiving obligations. They have difficulty maintaining work roles while assisting
family members.
 Caregiver burden and depressive symptoms are the most common negative outcomes of providing care for
the elderly and chronically ill. If the care recipient wanders (associated with Alzheimer’s disease) or displays
unsafe behaviour, the caregiver has to be alert and on call for supervision 24 hours per day. The constant
concern for managing disruptive behaviours (such as turning on stoves, walking into the street, taking too
many pills, yelling, screaming, or cursing) also affects the caregivers negatively.
The Potential for Harm

Caregivers can place their family members at risk in two ways, and both situations are preventable. First, despite their
good intentions and hard work, if caregivers do not have the knowledge and skills to perform their work, they may
unintentionally harm their loved one. E.g. Untrained informal caregivers managing enteral nutrition or tube feeding
may result in tube displacement, tube clogging, infection, and dehydration—all of which can lead to a stressful
caregiving situation and hospital readmission.

A second concern is that the demanding work of caregiving can put caregivers at risk of engaging in harmful behaviors
toward their care recipients, particularly among caregivers of persons with cognitive impairments. Caregivers who are
at risk of depression while caring for spouses with significant cognitive or physical impairments are more likely to
engage in neglect or abusive behaviors, such as screaming and yelling, threatening to abandon or use physical force,
withholding food, hitting, or handling roughly.

ROLE OF NURSES

 Nurses need to communicate effectively with clients and caregivers to develop cost-effective plans of care and
achieve positive client outcomes. Nurses and other health care providers should not expect caregivers to be
responsible for sorting out relevant information and applying it to the care requirements for their family
members.
 It is important to provide information in a clear, understandable way through verbal, written, and electronic
methods. Caregivers want concrete information about medications, tests, treatments, and resources. They
also want time to have their questions answered. Nurses can provide anticipatory guidance for what the
caregiver can expect. This kind of information can relieve caregivers’ distress arising from uncertainties
 Skills training for caregivers to prevent back injuries, infection, and other potential risks inherent in the
caregiver situation.
 Comprehensive counselling sessions for spouses caring for a person with dementia help reduce depression.
However, even a simple one-to-one telephone call may be effective in helping the caregiver as client.
 Home visits and enhanced social support also can help reduce caregiver depression.
 Study shows that caregivers who used adult day care services for their relatives with dementia had significantly
lower levels of caregiver stress, anger, and depression after 3 months of this respite care than a control group
of similar caregivers who did not obtain this intervention.
 Given caregivers’ essential role in caring for their family members and the hazards they face in doing so, their
needs and capacities to provide care should be carefully assessed. Assessing the home and family care
situation is important in identifying risk factors for elder abuse and neglect.
 Proper maintenance, documentation and explanation of discharge reports, nursing home case transfer
reports, medication lists, and multidisciplinary reports by the nurses significantly improved caregiver’s
experience.
 Teaching caregivers how to manage specific patient problems can improve the caregiver’s well-being. For
example, not being able to sleep at night is a serious problem for caregivers of people with Alzheimer’s disease.
Teaching them how to improve their family members’ night time insomnia through daily walks and exposure
to light can improve sleep time for both the caregiver and care recipient.
 Caregivers need adequate resources to assure minimization of risk to the patient. More case management
programs may be useful to help ease this transition, promote safe and effective hospital discharges, and
support caregivers in their ongoing, post-hospital care. Nurses, preferably those trained in gerontological
nursing, have a key role in case management for frail older people. Extending nursing care beyond the hospital
boundary, nurses can help caregivers mobilize supportive resources in their natural network as well as formal
services.
 Randomized trials and large scale studies are needed for enhancing caregiver skills and minimizing caregiver
distress.
 USE OF HEARING AIDS & DENTURES

AIDS USED FOR IMPAIRED HEARING

HEARING AIDS

Hearing aids are electronic instruments worn in or behind the ear to make sounds louder. It is a personal amplifying
system that includes a microphone, and amplifier and a loud speaker

ASSISTIVE LISTENING DEVICES

Assistive listening devices include telephone and cell phone amplifying devices, pocket talkers, smart phone or tablet
"apps," and closed circuit systems (induction coil loops) in places of worship, theaters, and auditoriums

COCHLEAR IMPLANT

A cochlear implant is an electronic medical device that replaces the function of the damaged inner ear. Unlike hearing
aids, which make sounds louder, cochlear implants bypass the damaged hair cells of the inner ear (cochlea) to provide
sound signals to the brain.

DIFFERENT STYLES OF HEARING AIDS

There are three basic styles of hearing aids. The styles differ by size, their placement on or inside the ear, and the
degree to which they amplify sound.

Behind-the-ear (BTE) hearing aids consist of a hard plastic case worn behind the ear and connected to a plastic earmold
that fits inside the outer ear. The electronic parts are held in the case behind the ear. Sound travels from the hearing
aid through the earmold and into the ear. BTE aids are used by people of all ages for mild to profound hearing loss.

In-the-ear (ITE) hearing aids fit completely inside the outer ear and are used for mild to severe hearing loss. The case
holding the electronic components is made of hard plastic. Some ITE aids may have certain added features installed,
such as a telecoil.

Canal aids fit into the ear canal and are available in two styles. The in-the-canal (ITC) hearing aid is made to fit the size
and shape of a person’s ear canal. A completely-in-canal (CIC) hearing aid is nearly hidden in the ear canal. Both types
are used for mild to moderately severe hearing loss.

Because they are small, canal aids may be difficult for a person to adjust and remove. In addition, canal aids have less
space available for batteries and additional devices, such as a telecoil. They usually are not recommended for young
children or for people with severe to profound hearing loss because their reduced size limits their power and volume.

HOW TO USE A HEARING AID

 Insert aid with canal portion pointing into ear, press and twist until snug
 Turn aid slowly 1/3 or ½ volume
 A whistling sound indicates incorrect insertion
 Adjust volume to a level of comfortable for talking at a distance of 1m
 Initially wear aid 15-20 minutes daily, gradually increase to 10-12 hours
 Concentrate on conversation; request repeat if necessary
 Sit close to speaker in noisy situation
 Continue to be observant of nonverbal cues
  Make sure that hearing aid is turned on, is clean and has batteries

CARE OF HEARING AIDS

 Before insertion, check for cracks or rough edges

 Clean cerumen from tip with pipe cleaner
 If using two aids, it should be marked properly
 Batteries should be checked and changed periodically
 Remove or disconnect batteries when not in use
 Insert battery only when hearing aid is turned off
 Ear molds need replacement every 2-3 years
 Take care to prevent dropping of hearing aid
 Keep away from very hot or cold places
 Do not wear aid while bathing or perspiring heavily. Remove before using hairspray, perfumes, shaving lotions
 Store in a marked contained in a safe place
 Caregivers should receive special training on hoe to place them in the ear canal

DENTURES

Dentures are prosthetic devices constructed to replace the missing teeth; they are supported by the surrounding soft
and hard tissues of the oral cavity

ADVANTAGES OF DENTURES

Dentures can help patients in a number of ways-

1. Mastication- Chewing ability is improved by replacing edentulous areas with dentures

2. Aesthetics- The presence of teeth provide a natural facial appearance, and wearing a denture to replace
missing teeth provides support for the lips and cheeks and corrects the collapsed appearance that occurs after
losing teeth.
3. Phonetics- BY replacing the missing teeth, especially the anteriors, patients are better able to speak by
improving pronounciation of those words containing sibilants or fricatives
4. Self esteem- patient feels better about themselves\

TYPES OF DENTURES

Complete dentures are used when all the teeth are missing (can be either "conventional" or "immediate")

Partial dentures are used when some natural teeth remain

CARE OF DENTURES

 Denture should be taken out daily to let the tissue under the denture breathe for six to eight hours a day or
overnight. Without enough air, the tissue may become irritated or even infected. Always store your denture
in a container filled with water or denture cleaner. The denture may change shape if it dries out.
 It is natural to experience fullness of mouth, restriction of tongue, and excessive salivation in the beginning
(especially on the lower denture)
  Dentures can cause irritation, inflammation and ulceration of gums. Inspect mouth regularly and report any
problem. Contact dentist for any adjustment or irritations
 A minor adjustment or use of fixative agent or cushion is required to prevent painful problems
 Cleaning and massaging the gums atleast once a day increases circulation
 Cleaning
o Rinse after each use and clean dentures thoroughly everyday
o Place dentures in a cleaning solution when not in use and allow it to soak overnight or for atleast 4 hours
o Then, remove from cleansing solution and brush it
o Brush denture over sink lined with wash cloth or half filled with water to prevent breakage if dropped
o Hold denture securely in one hand, don’t squeeze and use denture paste, mild soap

JOURNAL REFERENCE

Effect of a combined walking and conversation intervention on functional mobility of nursing home residents.

Tappen, R., Roach, K., Applegate, E. B., & Stowell, P.

Purpose

Motor loss becomes evident in the later stages of Alzheimer’s disease, leading to gait disturbances that predispose
the individual to falls and subsequent injuries. The purpose of this study was to assess the effect of a combination of
exercise and conversation, compared with walking only exercise and conversation-only treatments, on the functional
mobility of frail nursing home residents with Alzheimer’s disease.

Design

A repeated-measures three-group design was used. Sixty-five nursing home residents with Alzheimer’s disease were
randomly assigned to one of three treatment groups: walking only, having conversation only, or walking and
conversing with the study nurses. Treatments were given for 30 minutes three times a week for 16 weeks. The
residents’ functional mobility was measured before initiation of the treatments and after 16 weeks of intervention.
At the end of the intervention period, descriptive statistics, the Student ttest, analysis of variance (ANOVA) and the
chi square test were used to compare the three groups.

Conclusions

As expected, the ambulation function of the participants in the “conversation only” group dropped dramatically.
Those participants who were assisted to walk without conversation demonstrated a dramatic drop in ambulation
function as well. Of all three groups, the least decline occurred in ambulation function over time in the group of
participants with whom the nurses carried on a conversation while these participants were being assisted to walk.
This information suggests that while attempting to maintain physical function in the patient with Alzheimer’s
disease, the nurse can best achieve this goal if socialization is incorporated into exercise sessions.

Implications for Practice

This study demonstrated that assisted walking with conversation can contribute to maintenance of functional
mobility in institutionalized patients with Alzheimer’s disease. Staff caring for these patients can promote patients’
acceptance of assisted walking through the use of effective communication strategies.
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