Nursing Needs of the

Older Person, Acute Care

 Older Person
—  Physically, cognitively or socially frail

—  prone to significant deterioration – decompensation

after apparently minor stressors

—  Frailty - person requiring help in activities of daily

living

—  Frailty contributes to long hospital stay, high

readmission rate, and high rate of use of long term
care after discharge
 The Older Person

—  Increasing number of frail older people

—  Requires acute care

Establishing a Relationship
with the Older Person
Helpful questions?
—  How can we develop better relationships between
patients, relatives and staff?

—  What are the needs of patients with dementia or

delirium?

—  What are the needs of patients with communication

difficulties?

—  What are the needs of patients who do not have

regular visitors?
 Helpful questions?
—  Who in my team exhibits best practice in seeing
among patients and relatives, who are connecting
with them and involving them?

—  What is it that these colleagues do?

—  Can they articulate what they do?

—  What could I learn from looking at how they work?

 Helpful questions?
—  What could I do differently from today?
—  What stops me from working in this way?

—  What support do I need to ask for to help me relate

better to my team, patients and/or relatives?

—  Who might have a role here – the chaplain, the

palliative care team, the gerontological nurse
specialist, the clinical psychologist?
Best Practice Statements
Bridges et al. (2009) Nursing Standard
 “Connect with me”

“See who I am” “Involve me”

Older
Person
 ‘See who I am’

—  Maintaining identity

—  The Older person want staff to know what is

important to them

—  Relatives want staff to value what they know about

the patient.
 ‘Connect with me’
—  Creating community

—  connection and two-way relationship with staff

gives patients and relatives the reassurance that
staff will care for them and meet their needs.

—  Responds to older people’s feelings of fear,

worthlessness and isolation from normal life that
are associated with admission to hospital.
 ‘Connect with me’
—  The relationship between a patient is a key factor
that either heightens or lessens these feelings.

—  Two-way relationships that reflect mutual

understanding and reciprocal caring are helpful to
patients and relatives.

—  The needs of the patient should come first, before

the needs of the organization.
 ‘Involve me’

—  Sharing decision making

—  Patients and relatives want to understand what is

happening and to be given ongoing involvement in
decision making.

—  Responds to the need that many older people have

to understand what is happening and to be involved
in decisions about their care and treatment.
Nursing Needs of the
Older Person
Hancock, et al. 2003
 Physical
Care

Discharge Nursing Psychosocial

Planning
Needs Care

Doctors
orders
 Physical Needs

Rest and Sleep, Physical Comfort, Positioning,

Cleanliness

Food, Fluids

Exercise and Environment

 Psychosocial Needs

Emotional Support

Communication with the patient

and family

Spiritual, Religious and Diversional

Activities
 Doctors’ Orders

Observing Doctors’ Orders

Reporting of Nursing and Medical treatments

Carrying out Doctors’ Orders

 Discharge Planning

Health teaching

Arranging for continuity of care and assistance

at home
 Keep in Mind!
—  Nurses should routinely be able to COMMUNICATE the
reasons for the particular care activities to patients and
family and significant others
—  Include patients and family in decision making

—  Keep an older-friendly environment

—  Geriatric experts to meet the multi-dimensional care
needs

—  Emphasize on the older person’s strengths and

remaining abilities rather than focus on their deficits
and problems
Comprehensive Geriatric Assessment
—  A multidimensional,
interdisciplinary
diagnostic process to
determine the medical,
psychological and
functional capabilities of
a frail older person in
order to develop a
coordinated and
integrated plan for
treatment and long-term
follow-up
Comprehensive Geriatric Assessment
—  Team - geriatrician, nurse specialist, occupational
therapist, physiotherapist, pharmacist others as
needed

—  Team should be equipped with knowledge and the

skills and demonstrate appropriate behavior
 Main Domains of
Comprehensive Geriatric Assessment
—  Medical —  Mental Health
—  Comorbid conditions —  Cognition
and disease severity —  Mood and anxiety
—  Medication review —  Fears
—  Nutritional status
—  Problem list
 Main Domains of
Comprehensive Geriatric Assessment
—  Functional Capacity —  Social Circumstances
—  Basic activities of
daily living
—  Gait and balance
—  Activity/exercise
status
—  Instrumental
activities of daily
living
—  Informal support
available from
family or friends
—  Social network such
as visitors or
daytime activities
—  Eligibility for being
offered care
resources
 Main Domains of
Comprehensive Geriatric Assessment
—  Environment
—  Home comfort,
facilities and safety
—  Use or potential use
of telehealth
technology
—  Transport facilities
—  Accessibility to local
resources
 Recommendations in Assessment
—  Additional information and collateral history is crucial

—  Staff able to distinguish delirium vs dementia

—  Availability of aids to communication (hearing aid

batteries, visual aids)

—  Pain difficult to assess use pain scale

 Risks Associated with
Hospitalization
—  Delirium

—  Falls

—  Pressure Ulcers

—  Dehydration

—  Incontinence

—  Constipation

—  Loss of Functional Independence

 Surgical Care
—  Patients need to understand the increased success
of surgical procedures

—  Should be taught what to expect before, during and

after the operative procedure

—  Concerns, fears of patient should be relayed to the

physician
Surgical Care
—  Ensures that pre-op screening tests are complete

—  Infection control measures should be observed and

anticipated
 Surgical Care

Fluid and
Joint stiffness,
electrolyte Pressure ulcers
contractures
imbalance
• Malnutrition • Wound • Confusion.
• Pneumonia, dehiscence, delirium
atelectasis evisceration • Cardiac failure
• Hypothermia
During Emergencies
—  Maintain life functions

—  Prevent and treat shock

—  Keep the patient physically and psychologically

comfortable

—  Observe and record signs, treatments and responses

—  Assess for causative factors

Keep in Mind!
—  When an emergency condition is suspected, it is
better to err on the safe side and obtain the
diagnostic tests rather than risk delaying the
diagnosis
Selected Emergency
Situations
—  Acute Confusion/ Delirium
—  Note: Need for thorough evaluation.
This may result from a variety of
conditions, hypoglycemia, hypercalcemia,
malnutrition, infection, trauma and drug
reactions
—  Dehydration
—  Note: Factors that lead to dehydration like
decreased thirst sensation, disabilities that
restrict independent fluid intake, altered mental
status
Selected Emergency Situations
—  Falls
—  Note: an older person who falls once is at great
risk of falling again; prevention is necessary
morbidity and mortality associated with falls
increase with age

—  Myocardial Infarction

 Infection control
—  Atypical presentation of symptoms, low body
temperature, reduced cough efficiency
 Factors contributing to high risk
for infection
—  Age related changes

—  High prevalence of chronic

disease

—  Immobility

—  Greater likelihood of malnutrition, urinary catheter

use, invasive procedures, hospitalization,
institutionalization
Factors contributing to high risk
for infection
—  Altered antigen-antibody response

—  Decrease respiratory activity

—  Reduced ability to expel secretions from lungs

—  Weaker bladder muscles facilitating urinary retention

Factors contributing to high risk
for infection
—  Prostatic hypertrophy

—  Increased alkalinity of vaginal secretions

—  Increased fragility of skin and mucous membrane

 Nurses Improving Care for
Healthsystem Elders
(NICHE) Models of Care
—  Geriatric Resource Nurse (GRN) Model

—  Acute Care of the Elderly (ACE) Unit

 Geriatric Resource Nurse
(GRN) Model

—  Goal: improve the knowledge and expertise of the

bedside nurse on geriatric

—  Educational and clinical intervention

—  Prepares the staff nurse as the resource person on

geriatric issues to other nurses in the unit

—  First step in developing and implementing geriatric

initiatives
Reasons to implement the GRN model
—  Enhance the nurse/patient relationship and patient
satisfaction

—  Promotes the effectiveness of the interdisciplinary team

—  Increase implementation of evidence based clinical

practice
Reasons to implement the GRN model
—  Provide optimal utilization of hospital services

—  Facilitate safe and effective discharges

—  Promote continuity of care between the hospital and

other settings
Reasons to Implement the GRN model

—  Provide excellent bedside nursing to older adult patients

—  Develop a corps of nurses armed with clinical

competencies to meet the patients’ needs

—  Stimulate interest in gerontologic care and elder care

services
Reasons to Implement the GRN model

—  Develop incentives and improve morale for nurses caring

for the older adult

—  Provide a mechanism for professional growth of nurses

 Acute Care of the Elderly
(ACE) Unit
—  Designates a specific unit or section of a unit to deliver
interventions known to improve the clinical outcomes of
older adult patients.
 Acute Care for the Elders
(ACE) Unit
—  In patient service

—  Dedicated to provide best possible care to the older

person

—  Proven to reduce complications of hospitalization

—  Improve quality of life

—  Care Team

 Features of the Unit
—  Private, spacious rooms

—  Private bathrooms

—  Quiet ; separate from other hospital services

—  Non-skid floors

 Features of the Unit
—  Beds that be lowered with pressure –reducing
mattress

—  Bedside recliners

—  Soft lighting and warm color paint on walls

—  Family gathering areas

Keep in MIND!
—  Make correct assessment

—  Provide a friendly environment to the older person

—  Experts on geriatric

—  Know the risks

[Health care] is not a grand machine, a
complex of physical facilities, advanced
pharmaceuticals, surgical techniques, or an
administrative system, however wonderfully
conceived. It is instead an essentially human
activity, undertaken and given meaning by
people in relationships with one another and
their communities, both public and
professional’
(Tresolini and Pew-Fetzer Task Force 2000).
 Studies on ACE Unit
—  Decreased length of hospital stay

—  Reduced hospital costs

—  Reduced acute hospital

readmissions

—  Less functional decline in activities of

daily living/ Increased functional capacity
Studies on ACE Unit
—  Reduction of delirium
prevalence

—  Patients were satisfied with the care

given in the ACE

—  Improved satisfaction of hospital stay

—  Greater recognition of abnormal functional status

and abnormal cognitive status
 Summary
—  Best practice statements in establishing relationship
with the older person

—  Nursing needs of the acutely ill elderly

—  Comprehensive Geriatric Assessment

—  Risk factors associated with hospitalization

—  Care of elderly for surgery and during emergencies

—  NICHE Models of Care

Thank you for Listening
References
—  Bridges, Jackie, Flatley M. Meyer J.,Nicholson, C. Best
Practice for older People in Acute Care Setting:
Guidance for Nurses (2009), Nursing Standard, City
University London, 2009
—  Hancock, Karen, Chang, E., Chenoweth L., Clarke M.
Carroll, A, Jeon Yun-Hee. 2003.Nursing Needs of Acutely
ill Older People. Journal of Advanced Nursing, 44 (5):
507-516.

—  Edwardson, David, Nay, R. Acute Care and Older People:

Challenges and Ways Forward. Journal of Advanced
Nursing, 27 (2). P. 63-69
References
—  Royal College of Physician 2012. Acute Care Toolkit 3.
Acute Medical Care for Frail Older People. March .1-6.

—  Wald, H., Glasheen, J., Guerrasio, J. Youngwerth, J.,

Ulysses, E., 2011. Evaluation of a Hospitalist –run Acute
care for the Elderly Service. Journal of Hospital
Medicine.6 (6): 313-321.

—  Ahmed, N., Taylor, K. McDaniel, Y., Dyer, C., 2012. The
Role of an Acute Care for the Elderly Unit in Achieving
Hospital Quality Indicators While Care for Frail
Hospitalized Elders. Population Health Management. 15
(4).236-241
References
—  Ahmed, N., and Pearce, S. 2010. Acute Care for the
Elderly: A Literature Review. Population Health
Management. 13 (4). 219-225.