(
one step beyond by Julie Kluttz
Julie Klutzz, R.N ., C.A .N. A.-l, was one of the f irst nurses to be Certified in Geriatric N ursing Practice by the A .N. A . in December. 1974. She is now a member of the Geriatric Test Sp ecification Committee. A s an Ass istant Head N urse at The Wesley Nursing Center, a 277-bed sk illed nursing f acility, she is able to develop and use the sk ills requi red through her interest in the area of Gerontological N ursing.
The nurse working with geriatric patients must have a thorough knowledge of the aging process. She must be tireless in her efforts to use all tools and resource persons at her dispo sal, to pla n and implement care that will restore her patients to their opt imal le vel ofphysical and em otional health. Rehabilitation should be the fo cus in ever y nursing home or skilled nursing facilit y. Many nurses think of renamnrauon only In rne (orrnaf sense o( ph ysical /hef apJ',
srrok» fehalJ})iIaI}017
sod/or
1I0['al}017a)
retraining. With the elderl y, rehabilitation is an integral part of ever y experien ce between patient, nurse, ph ysician and auxiliary worker. One doc, not tea ch an elderly patient to walk and then ignore confusion and disorientation which would demand that the patient be physically restrained to prevent self-inj ur y; one sho uld not attempt to control co nfus io n, exces sive patient demands and physical illn ess by requesting sym toma tic drug therapy. Instead, the knowledgeable geriatri c nur se will go abou.t thorough, methodical, patient assessment. She will use nursing diagnoses and consulta tio n with other di sciplines to discern ways to correct patient problems with nursing measures. In order to mobilize all di sciplines in aiding the patient, the professional nurse serves as the liaison between the patient and everyone who can serve his needs. It is the knowledgeable nurse who mu st assess, plan, implement and evaluate procedures that will lead the older pat ient toward his fulle st potential. Hi s last yea rs sho uld prov ide him a time to look back and review his life a nd then - with understanding sup port - face his last yea rs in a wa y that provides sa tisfactio n and acceptance. It is the nurse ' s duty to see that both the ph ysical and mental health of the patients in her ca re are brought to and maintained at an optimal level. It is the nurse's responsibility to help the patient de term ine what is possible, and then, help him attain th at goal. This is geriatric nursing and rehabilitation nursing. PROBLEMS OFTHE ELDERLY Some important aspect s to consider during the assessment of the patient and the planning of his care
are: his adjustment to a new environment, the state o f his nutrition and the degree to which he is coping with chronic disease and th e normal aspects of th e aging process. The goals a nurse a nd pat ient hope to achieve a re based fir st on his adj us tment to his en vironm ent; it takes time - a week , a month , even three months. When a person enters a nu rsin g home, he has not onl y
left his (amily, home and perhap~ community, aut o((err
Re KROWJ IRal he wi)) Raef rasr». He mml , if? dfca,
face death. In any case, th e person feels loss of independence and choice . These problems mu st be de alt with before an y gr eat adva nces can be made in other areas of care. Con cornrnitanrly , the elderl y per son is likely to exhibit emotional d istress which ma y take th e form of confusion, d isorient ation , ho stilit y and /or depression. It is wise to co nsider these manifestat ion s as part of the adjustment process and look for ways to improve the situation, rather th an to label the patient as senile . There are very few persons ad m itted to nursing hom es who do not show so me form of nutritional deficit; unless this is an obviou s malnutrition, it is often overlooked. This, too, can affect the mental status of the patient. The nurse sho uld pa y extremely clo se attention to food and fluid int ake and habit s in the early day s after admi ssion . Th e co nd itio n of mouth and dentures must be assessed, a lo ng with an y ph ysical problems that might co ntribute to inadequate nutriti on. Often, interval feedin gs or multiple small meal s may be used to great ad vantage. G ro up meal s also help, unless the patient adamantl y refu ses to participate or is ph ysically unable to go to a dining room . Canned nutritional supplements mixed with ice cream mak e a very acceptable milk sha ke ; these supplemen ts pr o vide extra vitamin s and usually iron. Hemoglobin levels a re often noted to rise higher with these supplements th an with iron in tablet form . The degree of success th at the patien t exhibits in coping with his problems, sho ws the nurse earl y, how slo wly or quickly to proceed toward implementati on of long range plans.
Continued from page 20 Nursing the older person is as different as nursing children, and anyone who works extensively with the aged in any setting should avail herself of the increasing body of knowledge concerning normal aging and the nursing care of the ill aged. There are community college courses in gerontology, an increasing number of continuing education offerings and periodical publications devoted to this field. It is the intent of this article to give some thought to several areas found through experience to be extremely important in restoring the ill aged person to his fullest potential. STANDARDS OF CARE First, let us consider standards of practice. The Geriatric Standards of Nursing Practice, as set forth by the American Nurses' Association in 1970, provide a framework for nursing of the aged person and a guide in the areas of problem assessment and rehabilitation. The first two standards set the stage for gerontological nursing. Number one concerns our appreciation of the heritage, values and wisdom of the older person, and the second concerns the nurse's own attitude towards aging, dependency and death. These standards require that the nurse involves the aged patient in his own goal-setting and care. He is often completely aware of his capabilities, and moreover, he knows what is important to him. He may be ready to give up wordly responsibility, yet cling to personal independence over great obstacles. The nurse who feels that the patient should be protected and ministered to would, in this case, be doing the patient a disservice, fostering dependency needs because she "loves old people" and wants to "take care of them." She must know when to help and when to let go, and must allow the patient to assume charge of his own life as much as possible. Standard three deals with the nurse's ability to observe and differentiate between normal and pathologic changes due to the aging process and then to institute appropriate nursing measures. Older people may be so used to low-grade pain and debility that they ignore it completely. Sensory changes may come so gradually they go almost unnoticed. Standard four concerns the differentiation between pathologic social behavior and the usual life style of the person. A nurse cannot say a person is withdrawn or that his behavior is too far from the norm without knowing the person as an individual and without knowledge of his previous life-style and personality. Here again, she must be objective and non-judgmental in her assessment of the patient. Standards five and six deal directly with rehabilitation. The nurse "supports and promotes normal physiological functioning and attempts to protect the aged person from injury, infection and excessive stress," due to the manifestations of multiple chronic conditions. She must be acutely aware of the more rapid decline of the elderly person's health during acute episodes of illness. She must also be aware that rehabilitation is slower with the older person. Often
July-August 1976
results of restorative nursing can be gauged only in retrospect; therefore, re-assessment plays a vital part. One set of plans and goals is seldom enough; one must constantly assess, implement, evaluate and re-assess. Part of all rehabilitation is the promotion of effective communication and social interaction with individuals and families, (Standard seven). This is especially important with patients who have multiple sensory losses, aphasia and changes in mental status. If it is expected that the person will be discharged from the nursing home or convalescent center, this standard will have to be used extensively in dealing with discharge planning and family counseling. Standard eight says, that "the nurse and patient must design, change or adapt the physical and psychosocial environment to meet his needs within the limitations imposed by the situation." The nurse is called upon to usc ingenuity, imagination and creativity. She must be a patient-advocate, convincing others of the necessity for change. She must think of new and different ways to solve problems, must provide sensory stimulation and opportunities for learning and expanding the shrinking horizons of her patient, and must again help the family to understand older members with their special needs. The last standard is uniquely rehab-oriented. It deals with obtaining and utilizing devices to help the patient attain higher levels of function and insuring that these devices are kept in good working order. This brings to mind wheel chairs, hearing aides, eye glasses, and all the manifold equipment the older patient requires. It behooves the nurse to have a good basic knowledge about the care and cleaning of hearing aides, and to know that cataract glasses are worse than useless when not in proper adjustment! It will help, too, if she becomes handy with a screwdriver and oil can, so that she does not wait hours or days to get wheel chair pedals and brakes, or bed side-rails properly and safely adjusted and repaired. Advocacy comes in here also. The nurse finds out when the patient last had a visual examination, or she observes for sensory loss not immediately apparent after a stroke, and goes about securing orders for diagnostic procedures, so that proper care may be given. Another area that demands the alert nurse is that of medication. Due to the slowing down of bodily function, the loss of nephrons and kidney function and chronic disease, medications often cannot be given in the same dosages and expected to obtain the same results as, for example, with a 40-year-old person. Solely from experience and observation, it seems accurate to say that inappropriate or excessive medication are often the major problems of an older patient. Medication may obscure important symptoms, or it may cause symptoms that take up time to assess. A simple "discontinue" order might take away weeks of worry and defeat in the rehabilitation process. That is not to say that all medication is undesirable - only that medication for older people must be thoroughly evaluated and carefully selected. In a nursing home, the nurse plays a vital role in helping the physician. She must evaluate and question; she must make her ob-
an
Page 21
Continued from page 21 servations known to the physician. She must consult with the pharmacist. Unless the nurse puts herself in this role, she is not showing the diligence and courage necessary to protect her patients. However, this requires knowledge and judgment, and experience with drugs and their effects. She must be able to approach the physician as one professional to another. The concerned and effective nurse tries alternate approaches to problem-solving before asking the physician for additional patient medication. In the long run, other approaches may obtain better and more far-reaching results. In most nursing homes, there are experts in many areas of patient care. The nurse should utilize these people, if only on a consultative basis. The nurse or therapist in physical therapy can be valuable as a teacher and advisor, especially with auxiliary staff. She can teach range of motion, use of walkers, and proper transfer techniques. She can show how exercise and ambulation may be carried out as a part of routine activities. The chaplain is often a valuable person to help with family problems. The dietitian can offer suggestions concerning the patient's nutrition. There are other things to be considered when thinking of rehabilitation of older people, but the ones discussed here are the tools that geriatric nurses use, day after day, with all their patients. There are seldom one or two great rehabilitation goals to reach with old people; rather, we strive toward restoring the whole person with whatever methods we find will work - perhaps physical therapy, reality orientation, remotivation, or simply touching and listening. The two latter are often overlooked as insignificant, but are extremely important with the aged as an adjunct to all other attempted therapies. To one who works with the aged, rehabilitation means going one step beyond where they are today. At times, if we fall two steps back, we must begin again to go forward - and one step beyond. Editorial note: References to Geriatric Nursing Practice Standards used in this article are with the express permission of the American Nurses' Association.
CALENDAR OF EVENTS
Dear Editor: A colleague recently shared a copy of the January-February 1976 issue of the ARN Journal with us. We are delighted to see a journal devoted to rehabilitation nursing. There has long been a need for such a journal. We would like to make several comments on Greer G. Levine's article "Bowel Retraining for Spinal Cord Patients" which appeared in this issue. Levine perpetuates a common misconception related to the movement of the diaphragm during the Valsalva maneuver when she states in several places that the diaphragm descends during the maneuver. The Valsalva maneuver is a sustained, forcible exhalation against a closed glottis. During forced exhalation, the thoracic and abdominal muscles contract and the diaphragm ascends (as in normal exhalation) with a resultant increase in intrathoracic and intra-abdominal pressures. There are several inaccuracies related to the origin and function of the vagus nerve in this article which we would like to comment upon: 1. It is stated that stimulation of the vagus can cause relaxation of the external sphincter. The relaxation of the anal sphincter is under the control of the voluntary (somatic efferent) division of the nervous system not of the vagus. 2. The article implies that the vagus innervates the rectum. The parasympathetic innervation to this area is supplied by fibers from sacral cord segments 2, 3, and 4 and not from the vagus. 3. The article states that the patient with a Brown-Sequard syndrome has only one intact vagus nerve. In fact, the Brown-Sequard syndrome is the result of a hemisection of the spinal cord. Since the vagus nerves originate in the medulla, vagal pathology is not a component of the Brown-Sequard Syndrome. Sincerely, Anna Belle Kinney, R.N., M.N. Assistant Professor Mary Blount, R.N., M.N. Clinical Specialist, Neurological Nursing University of Virginia Charlottesville, Virginia 22903
- ARN 2nd Annual National Educational Conference and Business Meeting Washington, D.C., Stouffer's National Center Inn October 3-6,1976 - American Congress of Rehabilitation Medicine San Diego, California November 7-9, 1976 Page 22
Be sure your institution is as up-to-date as you are suggest that they subscribe to the ARN JOURNAL. See page 6.
July-August 1976
one step beyond by Julie Kluttz
Julie Klutzz, R.N ., C.A .N. A.-l, was one of the f irst nurses to be Certified in Geriatric N ursing Practice by the A .N. A . in December. 1974. She is now a member of the Geriatric Test Sp ecification Committee. A s an Ass istant Head N urse at The Wesley Nursing Center, a 277-bed sk illed nursing f acility, she is able to develop and use the sk ills requi red through her interest in the area of Gerontological N ursing.
The nurse working with geriatric patients must have a thorough knowledge of the aging process. She must be tireless in her efforts to use all tools and resource persons at her dispo sal, to pla n and implement care that will restore her patients to their opt imal le vel ofphysical and em otional health. Rehabilitation should be the fo cus in ever y nursing home or skilled nursing facilit y. Many nurses think of renamnrauon only In rne (orrnaf sense o( ph ysical /hef apJ',
srrok» fehalJ})iIaI}017
sod/or
1I0['al}017a)
retraining. With the elderl y, rehabilitation is an integral part of ever y experien ce between patient, nurse, ph ysician and auxiliary worker. One doc, not tea ch an elderly patient to walk and then ignore confusion and disorientation which would demand that the patient be physically restrained to prevent self-inj ur y; one sho uld not attempt to control co nfus io n, exces sive patient demands and physical illn ess by requesting sym toma tic drug therapy. Instead, the knowledgeable geriatri c nur se will go abou.t thorough, methodical, patient assessment. She will use nursing diagnoses and consulta tio n with other di sciplines to discern ways to correct patient problems with nursing measures. In order to mobilize all di sciplines in aiding the patient, the professional nurse serves as the liaison between the patient and everyone who can serve his needs. It is the knowledgeable nurse who mu st assess, plan, implement and evaluate procedures that will lead the older pat ient toward his fulle st potential. Hi s last yea rs sho uld prov ide him a time to look back and review his life a nd then - with understanding sup port - face his last yea rs in a wa y that provides sa tisfactio n and acceptance. It is the nurse ' s duty to see that both the ph ysical and mental health of the patients in her ca re are brought to and maintained at an optimal level. It is the nurse's responsibility to help the patient de term ine what is possible, and then, help him attain th at goal. This is geriatric nursing and rehabilitation nursing. PROBLEMS OFTHE ELDERLY Some important aspect s to consider during the assessment of the patient and the planning of his care
are: his adjustment to a new environment, the state o f his nutrition and the degree to which he is coping with chronic disease and th e normal aspects of th e aging process. The goals a nurse a nd pat ient hope to achieve a re based fir st on his adj us tment to his en vironm ent; it takes time - a week , a month , even three months. When a person enters a nu rsin g home, he has not onl y
left his (amily, home and perhap~ community, aut o((err
Re KROWJ IRal he wi)) Raef rasr». He mml , if? dfca,
face death. In any case, th e person feels loss of independence and choice . These problems mu st be de alt with before an y gr eat adva nces can be made in other areas of care. Con cornrnitanrly , the elderl y per son is likely to exhibit emotional d istress which ma y take th e form of confusion, d isorient ation , ho stilit y and /or depression. It is wise to co nsider these manifestat ion s as part of the adjustment process and look for ways to improve the situation, rather th an to label the patient as senile . There are very few persons ad m itted to nursing hom es who do not show so me form of nutritional deficit; unless this is an obviou s malnutrition, it is often overlooked. This, too, can affect the mental status of the patient. The nurse sho uld pa y extremely clo se attention to food and fluid int ake and habit s in the early day s after admi ssion . Th e co nd itio n of mouth and dentures must be assessed, a lo ng with an y ph ysical problems that might co ntribute to inadequate nutriti on. Often, interval feedin gs or multiple small meal s may be used to great ad vantage. G ro up meal s also help, unless the patient adamantl y refu ses to participate or is ph ysically unable to go to a dining room . Canned nutritional supplements mixed with ice cream mak e a very acceptable milk sha ke ; these supplemen ts pr o vide extra vitamin s and usually iron. Hemoglobin levels a re often noted to rise higher with these supplements th an with iron in tablet form . The degree of success th at the patien t exhibits in coping with his problems, sho ws the nurse earl y, how slo wly or quickly to proceed toward implementati on of long range plans.
Continued from page 20 Nursing the older person is as different as nursing children, and anyone who works extensively with the aged in any setting should avail herself of the increasing body of knowledge concerning normal aging and the nursing care of the ill aged. There are community college courses in gerontology, an increasing number of continuing education offerings and periodical publications devoted to this field. It is the intent of this article to give some thought to several areas found through experience to be extremely important in restoring the ill aged person to his fullest potential. STANDARDS OF CARE First, let us consider standards of practice. The Geriatric Standards of Nursing Practice, as set forth by the American Nurses' Association in 1970, provide a framework for nursing of the aged person and a guide in the areas of problem assessment and rehabilitation. The first two standards set the stage for gerontological nursing. Number one concerns our appreciation of the heritage, values and wisdom of the older person, and the second concerns the nurse's own attitude towards aging, dependency and death. These standards require that the nurse involves the aged patient in his own goal-setting and care. He is often completely aware of his capabilities, and moreover, he knows what is important to him. He may be ready to give up wordly responsibility, yet cling to personal independence over great obstacles. The nurse who feels that the patient should be protected and ministered to would, in this case, be doing the patient a disservice, fostering dependency needs because she "loves old people" and wants to "take care of them." She must know when to help and when to let go, and must allow the patient to assume charge of his own life as much as possible. Standard three deals with the nurse's ability to observe and differentiate between normal and pathologic changes due to the aging process and then to institute appropriate nursing measures. Older people may be so used to low-grade pain and debility that they ignore it completely. Sensory changes may come so gradually they go almost unnoticed. Standard four concerns the differentiation between pathologic social behavior and the usual life style of the person. A nurse cannot say a person is withdrawn or that his behavior is too far from the norm without knowing the person as an individual and without knowledge of his previous life-style and personality. Here again, she must be objective and non-judgmental in her assessment of the patient. Standards five and six deal directly with rehabilitation. The nurse "supports and promotes normal physiological functioning and attempts to protect the aged person from injury, infection and excessive stress," due to the manifestations of multiple chronic conditions. She must be acutely aware of the more rapid decline of the elderly person's health during acute episodes of illness. She must also be aware that rehabilitation is slower with the older person. Often
July-August 1976
results of restorative nursing can be gauged only in retrospect; therefore, re-assessment plays a vital part. One set of plans and goals is seldom enough; one must constantly assess, implement, evaluate and re-assess. Part of all rehabilitation is the promotion of effective communication and social interaction with individuals and families, (Standard seven). This is especially important with patients who have multiple sensory losses, aphasia and changes in mental status. If it is expected that the person will be discharged from the nursing home or convalescent center, this standard will have to be used extensively in dealing with discharge planning and family counseling. Standard eight says, that "the nurse and patient must design, change or adapt the physical and psychosocial environment to meet his needs within the limitations imposed by the situation." The nurse is called upon to usc ingenuity, imagination and creativity. She must be a patient-advocate, convincing others of the necessity for change. She must think of new and different ways to solve problems, must provide sensory stimulation and opportunities for learning and expanding the shrinking horizons of her patient, and must again help the family to understand older members with their special needs. The last standard is uniquely rehab-oriented. It deals with obtaining and utilizing devices to help the patient attain higher levels of function and insuring that these devices are kept in good working order. This brings to mind wheel chairs, hearing aides, eye glasses, and all the manifold equipment the older patient requires. It behooves the nurse to have a good basic knowledge about the care and cleaning of hearing aides, and to know that cataract glasses are worse than useless when not in proper adjustment! It will help, too, if she becomes handy with a screwdriver and oil can, so that she does not wait hours or days to get wheel chair pedals and brakes, or bed side-rails properly and safely adjusted and repaired. Advocacy comes in here also. The nurse finds out when the patient last had a visual examination, or she observes for sensory loss not immediately apparent after a stroke, and goes about securing orders for diagnostic procedures, so that proper care may be given. Another area that demands the alert nurse is that of medication. Due to the slowing down of bodily function, the loss of nephrons and kidney function and chronic disease, medications often cannot be given in the same dosages and expected to obtain the same results as, for example, with a 40-year-old person. Solely from experience and observation, it seems accurate to say that inappropriate or excessive medication are often the major problems of an older patient. Medication may obscure important symptoms, or it may cause symptoms that take up time to assess. A simple "discontinue" order might take away weeks of worry and defeat in the rehabilitation process. That is not to say that all medication is undesirable - only that medication for older people must be thoroughly evaluated and carefully selected. In a nursing home, the nurse plays a vital role in helping the physician. She must evaluate and question; she must make her ob-
an
Page 21
Continued from page 21 servations known to the physician. She must consult with the pharmacist. Unless the nurse puts herself in this role, she is not showing the diligence and courage necessary to protect her patients. However, this requires knowledge and judgment, and experience with drugs and their effects. She must be able to approach the physician as one professional to another. The concerned and effective nurse tries alternate approaches to problem-solving before asking the physician for additional patient medication. In the long run, other approaches may obtain better and more far-reaching results. In most nursing homes, there are experts in many areas of patient care. The nurse should utilize these people, if only on a consultative basis. The nurse or therapist in physical therapy can be valuable as a teacher and advisor, especially with auxiliary staff. She can teach range of motion, use of walkers, and proper transfer techniques. She can show how exercise and ambulation may be carried out as a part of routine activities. The chaplain is often a valuable person to help with family problems. The dietitian can offer suggestions concerning the patient's nutrition. There are other things to be considered when thinking of rehabilitation of older people, but the ones discussed here are the tools that geriatric nurses use, day after day, with all their patients. There are seldom one or two great rehabilitation goals to reach with old people; rather, we strive toward restoring the whole person with whatever methods we find will work - perhaps physical therapy, reality orientation, remotivation, or simply touching and listening. The two latter are often overlooked as insignificant, but are extremely important with the aged as an adjunct to all other attempted therapies. To one who works with the aged, rehabilitation means going one step beyond where they are today. At times, if we fall two steps back, we must begin again to go forward - and one step beyond. Editorial note: References to Geriatric Nursing Practice Standards used in this article are with the express permission of the American Nurses' Association.
CALENDAR OF EVENTS
Dear Editor: A colleague recently shared a copy of the January-February 1976 issue of the ARN Journal with us. We are delighted to see a journal devoted to rehabilitation nursing. There has long been a need for such a journal. We would like to make several comments on Greer G. Levine's article "Bowel Retraining for Spinal Cord Patients" which appeared in this issue. Levine perpetuates a common misconception related to the movement of the diaphragm during the Valsalva maneuver when she states in several places that the diaphragm descends during the maneuver. The Valsalva maneuver is a sustained, forcible exhalation against a closed glottis. During forced exhalation, the thoracic and abdominal muscles contract and the diaphragm ascends (as in normal exhalation) with a resultant increase in intrathoracic and intra-abdominal pressures. There are several inaccuracies related to the origin and function of the vagus nerve in this article which we would like to comment upon: 1. It is stated that stimulation of the vagus can cause relaxation of the external sphincter. The relaxation of the anal sphincter is under the control of the voluntary (somatic efferent) division of the nervous system not of the vagus. 2. The article implies that the vagus innervates the rectum. The parasympathetic innervation to this area is supplied by fibers from sacral cord segments 2, 3, and 4 and not from the vagus. 3. The article states that the patient with a Brown-Sequard syndrome has only one intact vagus nerve. In fact, the Brown-Sequard syndrome is the result of a hemisection of the spinal cord. Since the vagus nerves originate in the medulla, vagal pathology is not a component of the Brown-Sequard Syndrome. Sincerely, Anna Belle Kinney, R.N., M.N. Assistant Professor Mary Blount, R.N., M.N. Clinical Specialist, Neurological Nursing University of Virginia Charlottesville, Virginia 22903
- ARN 2nd Annual National Educational Conference and Business Meeting Washington, D.C., Stouffer's National Center Inn October 3-6,1976 - American Congress of Rehabilitation Medicine San Diego, California November 7-9, 1976 Page 22
Be sure your institution is as up-to-date as you are suggest that they subscribe to the ARN JOURNAL. See page 6.
July-August 1976
