Grief

After studying Module 7: Lecture Materials & Resources, discuss the following:

Grief: define and describe the physical symptoms, psychological and social responses and its spiritual aspects.
Summarize the types of grief.
Although death is a universal human experience, please specify culture-specific considerations that exist regarding attitudes toward the loss of a loved one, including age (child or older adult) and cause of death.

Submission Instructions:

Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.

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Meiner, S. E., & Yeager, J. J. (2019).
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Chapter 27

Chronic Illness and Rehabilitation

Chronic disease affects physical, psychologic, and social aspects of lives of individuals and families.

Many with chronic illness become homebound; decreased outside contact leads to social isolation.

Chronic disease is the leading cause of death and disability in the United States.

Chronic Disease

Disease refers to a condition viewed from a pathophysiologic model, such as an alteration in structure and function; it is a physical dysfunction of the body.

Illness is what the individual (and family) are experiencing, how the disease is perceived, lived with, and responded to by individuals and families.

Disease vs. Illness

Noncommunicable illnesses that are prolonged in duration, do not resolve spontaneously, and are rarely cured completely (Bernall & Howard, 2016)

Nurses need to consider the illness related issues that the patient and family experiences.

Understanding the perception of and response to the disease will allow for a more individualized plan of care.

Chronic Disease Defined

Increase in chronic conditions is caused by: Lifesaving and life-extending technologies not previously available, increase in population of older adults, and increasing life expectancy

The health care system applies the “acute care model” to those individuals with chronic conditions, and as a result, the needs of older adults and what the system can provide do not match.

This results in fragmented care, inadequate or inappropriate care from the system, and dissatisfaction on the part of the patient.

Chronic Conditions

The State of Aging and Health in America (CDC, 2013) reports two out of three older Americans have multiple chronic diseases and account for 66% of the health care budget.

Nursing care needs to focus on increasing functional ability, preventing complications, promoting the highest quality of life, and, when the end stage of life occurs, providing comfort and dignity in dying.

Prevalence of Chronic Illness

Include hypertension, hyperlipidemia, heart disease, arthritis, diabetes, chronic kidney disease, ischemic heart disease, dementia, depression, and chronic obstructive pulmonary disease.

Repeated hospitalizations are common to treat exacerbations of heart disease, cancer, pneumonia, and stroke.

Women are hospitalized for injuries like hip fractures.

Most Frequently Occurring Chronic Diseases

Course of a chronic illness varies from one individual to another.

Variables that impact the disease include: socioeconomic factors, psychosocial factors, culture, and other contributing comorbid disease or illness

Older adults often view themselves as “well”; their disease is only one component of their life and not their identity.

Chronic Illness Experience

Concepts of health and illness are deeply rooted in culture, race, and ethnicity and influence an individual’s (and family’s) illness perceptions and health and illness behavior.

30% of the population is racially and ethnically diverse.

Nursing frameworks assist health care providers in providing culturally competent care.

Cultural Competency

Multiple definitions for quality of life exist most include physical, psychological, and social components; disease and treatment-related symptoms; and spirituality.

QOL is determined by the individual, not the health care provider.

Health-related quality of life (HRQOL) is a multi-dimensional concept used along with well-being to measure the impact of chronic illness, the treatments, and the corresponding related disabilities.

Quality of Life

Adherence is how well the patient manages the treatment plan.

Use of the five A’s to assist patients with the self-management aspects of their chronic disease: assess, advise, agree, assist, and arrange.

Also important to (1) advise the patient of the importance of the treatment plan, (2) establish agreement with the treatment plan, and (3) arrange adequate follow-up

Adherence in Chronic Illness

Understanding the relationship between the older adult’s social, psychologic, and physiologic needs is important for health care providers.

Adaptation to chronic illness: three frameworks for practice demonstrate the importance of controlling symptoms, managing the trajectory of the disease process, and engaging the patient in self-care

Discussed on next slides

Psychosocial Needs of Older Adults With Chronic Illness

Issues and concerns framework—examines the psychosocial needs of patients VS their physical needs

Trajectory framework—the illness trajectory is set in motion by the pathology of the patient, but the actions taken by the health care providers, patient, and family may modify the course.

Chronic Care Model—assists with the management of multiple chronic diseases and improve outcomes by providing a method of care coordination to improve patient self-care

Chronic Illness and Quality of Life

Powerlessness

Stigma

Social isolation

Chronic Illness Experience

Is educating and providing a treatment plan that allows the patient to be in charge of the management of the chronic illness and have open communication with health care providers

Nurse should guide, educate, and support older adults and their families in developing positive coping strategies.

The nurse serves as a resource for older adults and their families in solving care management problems.

The Chronic Care Model

Pain is a major issue.

Fatigue may be difficult to manage.

Immobility and activity intolerance predictor of ability to maintain or recover wellness

Sexual activity can be affected by many aspects of chronic illness.

Physiologic Needs of the Chronically Ill

Situational factors related to caring for adults with chronic illnesses contribute to caregiver stress.

Role strain—balancing the role as primary caregiver with other roles within the family network

Female caregivers experience a greater sense of burden and stress than male caregivers.

Caregivers’ Stress

Providing care not only to the patient but also to the caregiver

Get to know the caregiver

Provide information about the illness

Reassure the caregiver that feelings of frustration or helplessness are not unusual reactions

Referral to social worker

Respite services

Nursing Implications of Caregiver Stress

Rehabilitation: services and programs designed to assist individuals who have experienced trauma or illness that results in impairment that creates a loss of function, which can be physical, psychologic, social, or vocational

Gerontologic rehabilitation nursing is a specialty practice that focuses on restoring and maintaining optimal function while considering holistically the unique effects of aging on the person.

Rehabilitation

You are a nurse caring for a patient with several chronic illnesses and who lives with a daughter. Discuss some of the ways the nurse can assist the patient and daughter to adapt the their illness and improve their health outcomes.

Quick Quiz!

Answers will vary

Answer to Quick Quiz

Goal: maintain or improve function

Activities older adults enjoy can be incorporated into exercise and endurance training.

Helps with chronic illness and disease prevention

Endurance training, strength training, balance exercises, and flexibility exercises are important exercises for older adults.

Enhancement of Fitness and Function

Function is a useful measure in the diagnosis of illness and self-care deficits.

Functional independence measure (FIM) measures abilities in six areas: self-care, sphincter control, transfers, locomotion, communication, and social cognition.

Establishing a patient’s baseline level of functioning helps identify the patient’s strengths and rehabilitation potential.

Functional Assessment

First check mental status

Conduct specific assessments based on the degree of potential or actual disability

Ask what they can do VS cannot do

Safety screening for self-care limitations

Consider values and beliefs about quality of life

Completing a Functional Assessment

Within rehabilitation allows older adults to achieve a maximum level of functioning and increase longevity

In chronic illness involves behavioral change for positive lifestyle activities, accepting one’s condition and making the necessary adjustments, decreasing the risk of secondary disabilities, and preventing further disease, all while striving for optimal health

Health Promotion

A person with a chronic illness or disability finds taking health or ability for granted is no longer possible.

Older adults must reorganize their lives to enhance functional ability and rehabilitation.

The nurse may assist older adults with organization and maximize financial resources.

Life Issues

Nurses assist patients in setting and achieving goals that facilitate reintegration to former environments.

Improving range of motion

Improving endurance and tolerance for activity

Restoring functional ability to an acceptable level

Improving ambulation (if appropriate)

Maintaining safety

Goals must be the patient’s goals, not the health care provider’s goals of care.

Nursing Strategies

Chapter 29

Loss and End-of-Life Issues

Employment to retirement

Lifelong home to a smaller home or senior apartment

Very active to being less so

Health to chronic illness

Marriage to widowhood

Extensive social networks to smaller circles of family and friends

Losses Associated With Aging

Successful aging requires learning to deal with losses and adapting to changes over time

Loss: broad term that connotes losing or being deprived of something such as one’s health, home, or a relationship

Bereavement: the state or situation of having experienced a death-related loss

Grief: one’s psychologic, physical, behavioral, social, and spiritual reactions to loss

Mourning: used to refer to ritualistic behaviors in which people engage during bereavement

Definitions

Life transitions such as retirement, ill health, and death of loved ones evoke varying responses of grief.

Many older adults experience multiple losses with little time for grieving between losses.

Individual coping styles, support systems, ability to maintain a sense of control, griever’s health status, and spiritual beliefs all influence responses to multiple losses.

Response to Multiple Losses

Bereavement includes grief and mourning.

Death of a spouse is most significant loss.

Surviving spouses must take on new responsibilities while coping with the loss.

Perceived social support after death of a spouse has been shown to be a factor affecting adjustment of many surviving spouses.

Other factors: ambivalent or dependent relationships, mental illness, low self-esteem, and multiple prior bereavements

Bereavement

Bereavement adjustments are multidimensional.

It is a highly stressful process.

The overall effect on the physical and mental health is not as devastating as expected.

Older bereaved spouses commonly experience both positive and negative feelings simultaneously.

Loneliness and problems with the tasks of daily living are two of the most common and difficult adjustments.

The process is most difficult in the first several months.

Much diversity in how older adults adjust to the death of a spouse

Bereavement Experiences of Older Persons

Early phase: shock, disbelief, and denial

Middle phase: intense emotional pain and separation often accompanied by physical symptoms and labile emotions

Last phase: reintegration and relief occur as the pain gradually subsides and a degree of physical and mental balance returns

Phases of Normal Grief Reactions

Tearfulness, crying, loss of appetite

Feelings of hollowness in the stomach, decreased energy, fatigue, lethargy, and sleep difficulties

Tension, weight loss or gain, sighing, feeling something stuck in one’s throat, tightness in one’s chest or throat

Heart palpitations, restlessness, shortness of breath, dry mouth

Physical Symptoms of Grief

Feelings of sadness, guilt, anxiety, anger, depression, apathy, helplessness, and loneliness

Diminished self-concern, a preoccupation with the deceased, and a yearning for their presence

Some become confused and unable to concentrate

Grief spasms, periods of acute grief, may come when least expected.

Psychological Responses of Grief

Depends on the type of relationship and the definition of social roles within the relationship

Bereaved person must often learn new skills and roles to manage tasks of daily living.

Socialization and interaction patterns also change.

LGBT partners grieve differently because of previous experiences with discrimination.

Social Responses of Grief

Examination of meaning of life

Religion and spirituality can provide a stabilizing influence during grief.

Anger at God, sometimes followed by a crisis of faith and meaning, may accompany bereavement.

Gender, social class, ethnicity, and culture may influence one’s spiritual response to grief.

Spiritual Aspects of Grief

Anticipatory grief: grieving that occurs before actual loss

Disenfranchised grief: grief that is not validated or recognized by others

Complicated grief: four types

Chronic grief reactions

Delayed or postponed grief reactions

Exaggerated grief reactions

Masked grief reactions

Types of Grief

Ritualistic activities such as wearing dark clothes during bereavement or lighting candles for the dead

Processes related to learning how to live with one’s loss and grief

Mourning

Accept the reality of the loss—realize the person is dead

Experience or work through the pain of grief—prevents physical manifestations of pain

Adjust to an environment in which the deceased is missing—assuming roles that the deceased was responsible for

Emotionally relocate the deceased and move on with life—removing the emotional attachment

Four Tasks of Mourning

The meaning of a loss to a bereaved person has a significant effect on his or her responses to that loss.

Caregivers should explore the perceptions of the bereaved to understand and assist them as they mourn their loss.

The bereaved are encouraged to find or create new meaning in their lives and in the deaths of the deceased.

Meaning Making

Assist and support bereaved persons through the grieving process

Recognize that pain is a normal and healthy response to loss

Allow bereaved persons to accomplish the tasks of mourning in their own ways

Nursing Care

Simple tool to assess progress in bereavement is the 10-Mile Mourning Bridge (Worden,1991)

On the bridge, the 0 represents the time before grief; 10 reflects Worden’s last stage, where patients recover the emotional energy consumed by grieving and reinvest it in their own lives.

Nursing Assessment

Help the survivor actualize the loss, identify, and express his or her feelings.

Assist the survivor in living without the deceased

Facilitate the survivor’s emotional withdrawal from the deceased.

Provide the survivor with time to grieve.

Interpret “normal” behavior for the survivor.

Allow for individual survivor differences.

Provide continuing support for the survivor.

Examine the survivor’s defenses and coping styles.

Identify pathologic conditions and make appropriate referrals.

Principles of Grief Counseling

Used to facilitate successful progression through the grief process

Grief counseling is used to facilitate successful progression through the grief process—nurses may provide

Grief therapy is intended for those who are experiencing complicated mourning—skilled therapist necessary

Grief

Help the survivor actualize the loss.

Help the survivor identify and express feelings.

Assist the survivor in living without the deceased.

Facilitate the survivor’s emotional withdrawal from the deceased.

Give the survivor time to grieve.

Interpret “normal” behavior for the survivor.

Allow for individual survivor differences.

Worden’s Grief Counseling Principles (1 of 2)

Provide continuing support for the survivor.

Examine the survivor’s defenses and coping styles.

Identify pathologic conditions, make appropriate referrals.

Worden’s Grief Counseling Principles (2 of 2)

An older adult has moved through all the phases of grief when which of the following has occurred?

The patient cries every day for the deceased spouse.

The patient talks about the spouse as if the deceased is still in the hospital.

The patient takes on the daily chores of cooking and cleaning the house.

The patient talks about the spouse in the past tense.

Quick Quiz!

ANS: D

Answer to Quick Quiz

Major concerns are fears of a long debilitating illness, fears of being a burden, pain and suffering, quality of life, and fear of dying suddenly and not being found.

A person who has had positive experiences of coping and is relatively well adjusted usually approaches the stress of being close to death with adaptation and acceptance

Life review: process where one tries to make sense of life as a whole

Approaching Death: Psychologic Aspects

Religious beliefs and spiritual experiences play an important part when older persons make sense of their lives.

Dying or a threat of loss can trigger a crisis of faith, in which people question their previous beliefs in an effort to make sense of the present experience.

Assessing patients’ desires for religious and spiritual assistance is particularly important when they are dying.

Approaching Death: Spiritual Aspects

Adoption of the sick role may be accompanied by an acceptance of one’s fate.

Dying individuals may adopt a fighting stance, determined to do all they can to forestall death

The stance people take toward dying is affected by sociocultural, psychologic, and life history factors.

Death and dying have been regarded as taboo topics in American society.

Social isolation often results as friends and sometimes family seemingly abandon the dying person.

Approaching Death: Social Aspects

Terminal illness: a life expectancy of 6 months or less, which is the length of time determined by Medicare for receipt of hospice benefits

There is no clear definition of dying for older persons not diagnosed with a terminal illness; must be explored individually.

Death for older persons usually results from complications from one or more chronic illnesses rather than from a sudden, unexpected incident or illness.

Approaching Death: Physical Aspects

Stabilize vital functions

Adjust treatment plan

Relieve distressing symptoms and suffering

Assist patient and family interaction

Support patient and family in coping with death

Health Care Needs of the Dying

Predispose older persons to greater potential for problems in the following areas:

Hygiene and skin care

Nutrition

Elimination

Mobility and transfers

Rest and sleep

Pain management

Respiration

Cognitive and behavioral functioning

Age-Related Changes

Examine your own feelings about death and values regarding older people.

Requires knowledge of the complexities of gerontologic and end-of-life nursing combined with the knowledge, skill, and compassion necessary to deliver holistic care to both dying patients and their families

Nursing Care of the Dying

Careful and ongoing assessments must be made of physical, psychosocial, and spiritual needs.

Special attention to potential problem areas: skin integrity, respiratory status, nutrition, elimination, sensory abilities, cognitive functioning, comfort, and rest.

Psychosocial needs of dying person, family, and caregivers must be carefully assessed.

Spiritual needs of dying person

Nursing Care: Assessment

Older adults require more frequent assessment, application, and evaluation of the effectiveness of nursing strategies.

Particularly difficult problems include pain, dyspnea, constipation, urinary incontinence, restlessness, hallucinations and delusions, and nutritional problems.

Good communication

Educate and support families

Nursing Care: Strategies

Too often, life-support technology, tests, treatments, and drug therapy are used causing needless suffering.

Hospice refers to a philosophy of caring that can be implemented wherever the patient may be dying—at home, the hospital, or a nursing facility.

Palliative care refers to “an approach that improves the quality of life of patients through the prevention and relief of suffering-treating of pain and other problems, physical, psychosocial, and spiritual.”

Nurses caring for very ill older adults need to understand the legal status of advance directives, living wills, and DNR orders.

Environment and Care Services

Chapter 28

Cancer

Risk for developing cancer increases with age.

Adults over the age of 65 account for 60% of all new cancer diagnosis.

Most common cancers in older adults are: (1) lung cancer, (2) prostate and breast cancers, and (3) colon and rectal cancers.

Introduction

The number of new cases in a given time period, usually a year, in general population

Leading types of cancer in men are lung, prostate, and colorectal.

Leading types of cancer in women are lung, breast, and colorectal.

Many persons survive cancer.

Some cancers have relatively high incidence rates and relatively low death rates.

Cancer Incidence

Racial and ethnic group age cohorts demonstrate different patterns of cancer incidence.

Examination of patterns of cancer among racial or ethnic groups should include age and environmental considerations.

Race and ethnicity are highly correlated with socioeconomic status.

Racial and Ethnic Patterns

Cancer is a disease of aging.

Cancer develops from “genetic mutations that are either inherited or acquired through errors in DNA replication and environmental insults.”

Cancer results from cancer stem cells (CSCs) that retain their ability to proliferate repeatedly without losing their ability to initiate uncontrolled growth, leading to cancer.

Aging and Relationship to Cancer

Process of cancer growth is believed to occur in four steps: tumor initiation, tumor promotion, malignant conversion, and tumor progression.

Oncogenes are genes that produce abnormal codes for growth-regulating substances and are believed to play a role in the development of cancers because, once activated, they interfere with normal physiologic regulation of cell growth.

Oncogenes can cause improper regulation of cell growth, leading to cancerous transformation in normal cells.

Cancer Growth and Development

The study of what genes do and their interaction with each other

Cancer genome research studies the differences in genes found in tumors to understand which ones cause development and proliferation of a tumor.

Different genes are involved in different tumor types.

Learning which genes cause certain cancer has led to improvements in detecting, diagnosing, and treating cancer.

Researchers hope to develop drugs that target mutations on specific genes to stop the cancer’s growth.

Genomics

Aging increases the duration of exposure to substances that may act as promoting agents.

Aging cells demonstrate a tendency toward abnormal growth.

Once an aged cell is damaged by a carcinogen, it is more difficult to repair.

Oncogene activation might be increased in older persons.

Decreased immune surveillance may contribute to increased cancers development and progression.

How Aging Process Influences Cancerous Transformation of cells

Cancer risk is similar for a given birth cohort within specific environmental boundaries.

Older adults should be encouraged to consume the recommended daily requirements of fruits and vegetables because dietary habits may be beneficial in halting the cancer process.

Evaluation of environmental risk factors can lead to specifically targeted education and screening programs among selected high-risk cohorts.

Aging and Cancer Prevention

Most common type of cancer and leading cause of cancer death in both men and women

Lung cancer-related deaths have declined across all races and genders, but black men and women are at higher risk.

Lung Cancer

Cigarette smoking: the greatest lifetime cumulative exposure to cigarette smoking occurs between ages 70 and 80.

The risk of lung cancer decreases over time for ex-smokers.

Exposure to certain industrial substances

Long-term exposure to air pollution

Radiation exposure

Lung Cancer Risk Factors

One quarter of individuals have no signs and symptoms, or vague symptoms.

Classic clinical presentation is persistent cough, sputum streaked with blood, chest pain, fatigue and weight loss, recurring respiratory infections, shortness of breath, and hoarseness.

Lung Cancer Signs and Symptoms

Low-dose spiral computed tomography (LDCT) screening of current or former (quit within 15 years) smokers between the ages 55 and 74, who have at least a 30 pack year smoking history has been shown to reduce lung cancer mortality by about 20%.

Lung Cancer Early Detection

Options for treatment include surgery, radiotherapy, and chemotherapy, depending on the type and stage of disease.

Non–small-cell lung cancer (NSCLC) surgery is the treatment of choice, sometimes with chemotherapy, other times with radiation.

Advanced NSCLC, treatment is with chemotherapy and targeted drugs.

Small cell lung cancer (SCLC), chemotherapy is used, alone or combined with radiation.

Lung Cancer Treatment

Most common neoplasm in women, increasing in incidence with advancing age

Is the leading cause of cancer-related death in women ages 55–74

The primary presenting symptom is a lump in the breast.

Breast cancer is more common in Caucasian women than in other racial or ethnic groups.

African American women of all ages have the highest mortality rates from breast cancer.

Breast Cancer

Duration and intensity of exposure to estrogen, early menarche, late menopause, lengthy exposure to postmenopausal estrogen, recent use of oral contraceptives, and never having given birth or having first given live birth at a late age

Personal or family history of breast cancer, history of benign breast disease or dense breast tissue, excessive alcohol use, and smoking

Genetic basis: BRCA1 and BRCA2

Breast Cancer Risk Factors

Malignant lumps are hard and fixed, with irregular borders, and are sometimes described as frozen peas.

Nipple retraction or elevation

Skin dimpling may be present.

Localized erythema and warmth may be present.

Characteristically, edema appears as “orange peel” skin.

Breast Cancer Signs and Symptoms

Women should be familiar with how their breasts normally look and feel and report any changes to a health care provider right away.

Mammography is able to detect breast tumors before they present physical findings.

The American Cancer Society (ACS) recommends mammography screening every year for women after the age of 40, until age 54; those over age 55 may change to biennial mammography and should continue as long as overall health is good and life expectancy is 10 or more years.

Breast Cancer Early Detection

Surgery either lumpectomy or modified radical mastectomy for removal of primary tumor

Radiation after breast-conserving surgery or following mastectomy for large tumors or when cancer has spread to the lymph nodes

Lymph nodes should be evaluated.

Treatment may also involve chemotherapy, hormone therapy, and/or targeted therapy.

5-year survival rate for localized breast cancer, when caught early, is 99% and for regional breast cancer, it is 90%.

Breast Cancer Treatment

Average age at diagnosis is 66.

Although prostate cancer is serious, most men do not die from it.

Is usually adenocarcinoma that develops slowly in the gland cells of the prostate

Disease of aging

Risk factors include a family history of prostate cancer (before the age of 65), occupational exposure to carcinogens and smoking

Prostate Cancer

Asymptomatic in early stages

Signs and symptoms related to the increased growth of the prostate: weak or interrupted urine flow, difficulty or inability to begin urine flow, difficulty stopping urine flow, and urinary frequency, especially at night

As the cancer progresses: Pain in the hips, spine, and ribs (from bony metastases), impotence, weakness or numbness in the lower extremities, and bowel and bladder incontinence

Prostate Cancer Signs and Symptoms

Routine prostate cancer screening for men at average risk is not recommended due to concerns about the high rate of over diagnosis leading to potential for serious side effects associated with prostate cancer treatment.

Men age 50, with average risk and who have a life expectancy of at least 10 years, should discuss risks and benefits of screening with doctor.

Men at high risk (black men, or close relative diagnosed with prostate) should have this discussion beginning at age 45.

Prostate Cancer Early Detection

Active surveillance, surgery, external beam radiation, or radioactive seed implants used alone or in combination

Hormonal therapy may be used with surgery or radiation in advanced cases or used alone in patients who cannot have surgery or radiation.

Treatment choice is determined by age, comorbidities, stage and grade of the tumor, the likelihood of a cure, and what the patient wants.

Chemotherapy may be used for metastasis.

Prostate Cancer Treatment

Colorectal cancer is the third most common cancer.

Early screening with polyp removal, early diagnosis and treatment leading to cure, and improvements in treatment account for the declining rates.

Risk factors: Personal or family history of colorectal cancer, polyps, or inflammatory bowel disease and type 2 diabetes, diet, obesity, and sedentary lifestyle

Colorectal Cancer

Early stages: may not have symptoms

As disease advances: A change in bowel habits or stool shape, the feeling that the bowel is not completely empty, abdominal cramping or pain, decreased appetite, and weight loss

Early detection: Starting at age 50, both men and women should have yearly guaiac-based fecal occult blood tests; flexible sigmoidoscopy every 5 years, or colonoscopy every 10 years, or double-contrast barium enema every 5 years, or computed tomography (CT) colonography every 5 years

Colorectal Cancer Signs and Symptoms

Cancer stage guides treatment, but surgery is the treatment of choice

Permanent colostomy is seldom needed

Radiation therapy prior to surgery to shrink the size of tumor, or after surgery to reduce the chance of recurrence

Chemotherapy after surgery is used with cancer that has spread to the lymph nodes or cancer that has penetrated the bowel wall

Targeted therapies are used for treating advanced colorectal cancer

Colorectal Cancer Treatment

Older adults have had a lifetime of exposure to risk factors; changing lifestyles is advantageous, but changes may not reverse effects of exposure.

Detection of cancer at an early stage may greatly improve survival rates.

Screening guidelines vary greatly among different national organizations due to the lack of cancer screening trials that include older adults.

Screening and Early Detection Issues for Older Adults

Taking into account the older adult’s personal preference and health should be used rather than relying only on age guidelines.

Decision to screen or not to screen should be an active one; with input from a multidisciplinary health care team considering screening guidelines, individual circumstances, potential complications of aggressive evaluation workups, and associated costs

Decision Making Process in Screening

Is based on following factors:

Individualize the decision

Estimate life expectancy

Assess risk of cancer screening

Ascertain patient preferences

Consult various cancer screening guidelines

U.S. Preventive Services Task Force (USPSTF)

American Cancer Society and American Geriatric Society

Walter and Covinsky’s Framework for Cancer Screening

The nurse is teaching a group of older adults about health promotion, and cancer prevention. The nurse includes which of the following?

Lung cancer is the most common cancer and can be screened for by yearly chest x-ray.

Women who have never given birth or had late menopause are less likely to get breast cancer.

Since prostate cancer is slow growing, men should discuss getting screened with their physician.

To detect colon cancer early, colonoscopy should be done every 5 years.

Quick Quiz!

ANS: C

Answer to Quick Quiz

The nurse should teach older adults the following:

Change in bowel or bladder habits

A sore that does not heal

Unusual bleeding or discharge

Thickening or lump in the breast or elsewhere

Indigestion or difficulty swallowing

Obvious change in a wart or mole

Nagging cough or hoarseness

Early Warning Signs of Cancer

Five types of cancer treatment: (1) surgery, (2) radiation therapy, (3) chemotherapy, (4) targeted therapy, and (5) immunotherapy

Type of treatment is determined by the type and stage of cancer, unique biophysiologic characteristics of cancer cells, and patient’s overall health status at the time of diagnosis.

Major Treatment Modalities

Cure—elimination of disease

Control or minimization of disease

Palliation—relief of symptoms

Adjuvant therapies to standard therapies have been developed that include angiogenesis inhibition, gene therapy, hyperthermia, laser therapy, and photodynamic therapy.

Cancer Therapies

Functional status reported to be a more important pretreatment variable, influencing both the decision to treat and type of treatment

Number of comorbid conditions is a significant predictor of outcome of an older adult receiving cancer treatment.

Nurses should be sure patients and families have accurate information and a clear understanding of treatment options offered.

Patient Considerations in Treatment

Indicated for most solid tumors

Surgery also used: helps diagnose the disease, palliative care, placement of treatment-related devices, rehabilitation or restorative purposes

Not a treatment of choice for disseminated disease (metastasis)

Curability of cancer in older adults is largely predicted by an individual’s ability to tolerate major surgery.

Surgery

Priority: Preventing respiratory complications and promoting cardiac and renal function

Because of the overall reduced compensatory reserves in these systems, older adults are susceptible to many serious complications, including congestive heart failure, electrolyte imbalances, hypoxia, dehydration, and venous thromboembolism.

Stress of surgery and medications predisposes to delirium, paralytic ileus, and constipation.

Other possible complications include paralytic ileus and constipation and pressure ulcers.

Postoperative Concerns

May be curative for the treatment of several cancers

As adjuvant therapy prevents recurrence, controls cancers, shrinks the tumor, provides palliative care, relieves pain, and prevents pathologic fractures

Can also result in less disability and disfigurement than some extensive surgeries

Radiation therapy may involve external or internal techniques.

Age cannot be used as a predictor for how patients will respond to treatment.

Radiotherapy

Is systemic use of drugs to destroy cancer cells

Kills cancer cells either by damaging DNA, interfering with DNA synthesis, or inhibiting cell division

Combination chemotherapy is necessary to provide a better chance of long-term, disease-free survival.

Objectives of chemotherapy include cure, control, and palliation.

Chemotherapy

Pharmacokinetics refers to the movement of drugs throughout the body, including absorption, distribution, metabolism, and excretion.

Age-related changes in liver may result in reduced hepatic chemotherapy drug clearance.

Dosage of chemotherapeutic agents may need to be adjusted to account for age-related changes in the kidneys.

Pharmacodynamics refers to the interactions between the chemotherapeutic agents and their cellular targets.

All drugs act at the cellular level and their mechanisms of action varies, therefore nurses should understand the specific actions and side effects of individual chemotherapeutic agents.

Pharmacokinetics and Pharmacodynamics

Targeted cancer therapies are drugs that block the growth and spread of cancer by interfering with specific molecules (molecular targets) that are involved in the growth, progression, and spread of cancer.

They are a form of medicine that uses information about a person’s genes and proteins to prevent, diagnose, and treat disease.

Targeted Therapy

Type of cancer treatment designed to help the immune system fight cancer

Is a type of biological therapy treatment that uses substances made from living organisms to treat cancer

Includes monoclonal antibodies, adoptive cell transfer, cytokines, and vaccines

Immunotherapy

Most treatment pharmacodynamics includes the prevention of cell division; actively dividing cell types are particularly vulnerable.

Actively dividing cell types most likely to exhibit side effects: hematopoietic tissue, the gastrointestinal tract, and hair follicles

Chemotherapy side effects are specific to the type of agent, dosage, and duration of use.

Radiation-related side effects depend on location of radiation field, intensity of dose, and duration of therapy.

Common Physiologic Complications

The 85-year-old patient just received news that she has colon cancer in her sigmoid colon. The patient has severe COPD, CHF, and osteoarthritis in her hands. The nurse is reviewing the options the physician presented to the patient and the family at their request. The nurse includes which of the following to help them decide on a treatment modality? (Select all that apply.)

Although surgery is the treatment of choice, the patient has to be able to tolerate the procedure and post-op recovery.

The patient may have difficulty with self-care if a colostomy is performed.

The patient will most likely be able to tolerate chemotherapy without any problems.

Radiation therapy does not pose as much risk to the older adult patient.

Quality of life needs to be taken into consideration when choosing treatment.

Quick Quiz!

ANS: A, B, E

Answer to Quick Quiz

Is a decrease in the ability of the bone marrow to manufacture hematopoietic stem cells which differentiate into the red blood cells, white blood cells, and platelets that the body

Can result in anemia, neutropenia, and thrombocytopenia which may cause fatigue, lightheadedness, pallor, shortness of breath, and tachycardia, symptoms of infection and bleeding

Bone Marrow Suppression

Anemia—should improve after chemotherapy is completed; medication to stimulate red blood cell production and iron supplements; sometimes blood transfusions may be necessary

Neutropenia—avoid situations that could result in infection and medications to prevent infection or stimulate the production of white blood cells

Thrombocytopenia—platelet transfusion or medications to stimulate the bone marrow to make more platelets may be prescribed if bleeding is present

Bone Marrow Suppression Management

Wash hands properly.

Call the health care provider with any signs of infection (fever >100.5°F, coughing, chills, shortness of breath, or pain with urination).

Rest when tired and stand up slowly after resting.

Avoid aspirin and ibuprofen and take care to avoid situations where injuries may occur.

Bone Marrow Suppression Patient Teaching

Most distressing side effect

Not all chemotherapeutic agents cause nausea and vomiting.

Monitor for dehydration and electrolyte imbalances and renal failure

Current pharmacologic management includes corticosteroids, serotonin antagonists, dopamine antagonists, neurokinin 1 (NK1) receptor antagonists, cannabinoids, and anti-anxiety drugs.

Chemotherapy-Induced Nausea and Vomiting (CINV)

Destruction of rapidly proliferating mucosal cells in oral cavity resulting in inflammation, ulceration, pain, and bleeding

Teach patients good oral hygiene and avoiding products with alcohol.

Gargling with a solution of one quart of water, with half teaspoon of salt and half teaspoon of baking soda may sooth mucus membranes

Prescription products are also available.

Intravenous fluid administration may be necessary with severe mucositis.

Chemotherapy-Induced Oral Mucositis

General loss of appetite

Contributing factors: chemotherapeutic agents; radiotherapy, pain medications, and mucositis

Leads to decreased caloric intake and weight loss, which is linked to poor outcomes

Dietary consultation and frequent weight monitoring are necessary.

Anorexia

Results from destruction of actively dividing epithelial cells of the gastrointestinal tract

Absorption of nutrients is decreased, and patients are at risk for dehydration and malnutrition.

Can aggravate perirectal problems such as hemorrhoids and can cause pain, bleeding, and infection

Assessment includes number of stools per day, consistency, and color.

To control diarrhea, instructed patients to eat low fiber foods, small frequent meals, and to avoid coffee, tea, alcohol, sweets, fried, greasy, or spicy foods as well as milk and milk products

Diarrhea

Hair loss may range from thinning of scalp hair to total body hair loss, including eyelashes, eyebrows, and pubic hair.

Occurs rapidly and becomes apparent over a 2–3-week period after initiation of treatment

Hair begins to grow back slowly when treatment is completed.

The emotional distress can be enormous.

Wigs and hair pieces should be purchased before total hair loss occurs.

Alopecia

The patient is receiving chemotherapy and is experiencing several side effects, including myelosuppression, nausea and vomiting, diarrhea, and mucositis. The nurse provides which of the following interventions? (Select all that apply.)

Give antiemetic medication prior to meals.

Monitor for fluid and electrolyte imbalance.

Offer frequent oral hygiene with mouthwash.

Provide a high-fiber diet.

Administer blood and platelet transfusions as ordered.

Offer frequent small meals.

Quick Quiz!

ANS: B, E, F

Answer to Quick Quiz

For an older adult experiencing cancer in the context of a life mostly lived, quality is a very—if not the most—important consideration.

It is a multidimensional concept that includes not only functional status and severity of symptoms but also the patient’s ideas about psychologic development, sociocultural issues, ethical issues, economic issues, and spirit.

Quality of Life (1 of 2)

Evaluation is relevant to both curative and palliative care.

Curative care: information obtained from assessment can guide the selection of therapeutic strategies leading to a more normal life

Palliative care: assessment can provide insight into areas that may require intervention, such as family counseling, financial planning, and management of depression

Quality of Life (2 of 2)

Depressive symptoms may result from side effects of medications used to control cancer.

Understand how experience of cancer affects such things as feelings of well-being, interpersonal relationships, and self-fulfillment

Older patients and family members should be encouraged to discuss the effects of cancer on family functioning.

Individual evaluation of depressive symptoms is needed if the older person is suspected of experiencing depression.

Depression

An older adult being treated for cancer may experience multiple losses: loss of energy, loss of a body part, loss of functional ability, loss of self-esteem, and loss of control.

Intensity of grief is determined by the meaning an individual places on the loss.

Nurses should support older patients and families by patiently repeating information when asked, validating what the family has heard, and determining what the information means to them as individuals and as a family unit.

Grief and Loss

The sense of being cut off from people and things of importance, is an experience commonly described by older adults with cancer

Social isolation can have negative consequences on psychological health.

Risk factors: physical disability or illness, frailties associated with advanced age, psychological or neurologic disorders, and environmental constraints

Social isolation may be voluntary (i.e., a person seeks disengagement from social interaction) or involuntary (i.e., imposed by others or by circumstances).

Social Isolation

An important component to nursing care of older adults is awareness of resources and referrals to appropriate agencies or support groups.

Nurses should have up-to-date listings for the groups in their areas.

Web resources are also being used by older persons.

Resources and Support

Chapter 26

Health Care Delivery Settings and Older Adults

Most Common Diagnosis-Related Groups (DRGs) in Hospitalized Adults 85+

Heart failure

Pneumonia

Urinary tract infections

Cerebrovascular disorders

Digestive disorders

Gastrointestinal hemorrhages

Nutritional and metabolic disorders

Rehabilitation

Renal failure

Heart disease

Malignant neoplasms

Chronic lower respiratory disease

Cerebrovascular disease

Alzheimer’s disease

Major Causes of Death in Adults 65+

Arthritis, diabetes mellitus, hypertension, and heart disease are the most prevalent chronic diseases in older adults and are the leading causes of disability.

Chronic Conditions and Disability

Effective caregiving practices can enable older persons to maintain or improve their independence and to return to their preferred setting at discharge.

Focus needs to be on not only the restoration of health but also the promotion and preservation of health.

Focusing on a functional model addresses concerns related to medical and functional stability.

Philosophy of Care in the Acute Care Environment

Adverse drug reactions—polypharmacy

Falls—Risk factors for hospital falls include intrinsic and extrinsic factors

Infections—UTI, GI, skin, and bloodstream

Hazards of immobility

Unfamiliar environment

Risks of Acute Care Hospitalization

All staff members must have competency assessment specific to patient age groups that are being cared for in the assigned area.

Nursing expertise is particularly needed to guide staff in understanding the unique needs of older patients and enhancing their skill in managing common geriatric syndromes.

Advanced practice nurses can develop and implement protocols for managing common geriatric syndromes—like those defined in the geriatric triad.

Nursing-Specific Competency and Expertise

Includes falls, changes in cognitive status and incontinence

Falls—may be a classic sign of illness for older adults

A strange environment, confusion, medications, immobility, urinary urgency, and age-related sensory changes all contribute to this increased risk.

Geriatric Triad

Requires understanding of older adult’s impaired homeostatic mechanisms, their body systems’ diminished reserve capacity, and their impaired immune response

Must be aware of atypical and subtle common presenting symptoms of disease, i.e., mental status change

Astute observation for delirium

Prevention of nutritional compromise and recognition of adverse drug reactions

Critical Care and Trauma Care

Result of falls

Automobile accidents

Burns

Consequences are usually more severe.

Thermoregulatory mechanism is impaired, so trauma victims are more vulnerable.

Greater risk for complications and mortality

Most Common Traumatic Injuries

Need to be affordable and appropriate to assist older adults to remain in the home while maintaining their quality of life

Home health care, community-based alternative programs, respite care, adult day care programs, senior citizen centers, homemaker programs, home-delivered meals, and transportation are examples of community based care.

Community-based Services

Functional status: an individual’s ability to perform the normal, expected, or required activities for self-care

Functional status determines whether an older adult needs home health care or whether a home health client is recertified for home care services.

Adapting to functional limitations is crucial for maintaining independence.

Home health nurse must assess for functional impairments.

Functional Status

Another eligibility criterion used by various community programs

Change in cognitive status frequently signals change in another body system

Cognitive impairments are associated with functional limitations.

Cognitively impaired individuals often need supervision and cueing, rather than physical assistance, to perform ADLs and IADLs.

Cognitive Function

Older adults prefer to live independently, but it may not be appropriate.

Financial status, functional status, and physical health dictate consideration of alternative housing options.

Housing Options for Older Adults

Assessment of functional status aids in determining the type of services an older adult needs to remain in his or her home.

Formal community services: home health care, homemaker services

Informal community services: senior citizen centers, adult day care services, nutrition services, transportation services, and telephone monitoring services

Community and Home-Based Services

Services provided include information and referral for medical and legal advice; psychological counseling; preretirement and postretirement planning; programs to prevent abuse, neglect, and exploitation; programs to enrich life through educational and social activities; health screening and wellness promotion services; and nutrition services

Area Agencies on Aging

Community facilities that provide a broad range of services:

(1) Health screening; (2) health promotion and wellness programs; (3) social, educational, and recreational activities; (4) congregate meals; and (5) information and referral services for older individuals and their families

Funding for senior centers is provided primarily through the OAA and agencies such as the United Way.

Multipurpose Senior Centers

Provide a variety of health and social services to older adults who live alone or with their families in the community

Most users are frail or cognitively impaired and require assistance with ADLs.

Federally regulated

Medicaid is a major funding source for most of these programs; however, participants usually pay part of the fee.

Adult Daycare Services

Provides short-term relief or time off for persons providing home care to ill, disabled, or frail older adults

Adult day care services are a form of respite provided outside the home.

Private pay and state programs that target lower income families are the two main funding sources.

Respite Care

Include such things as housecleaning, laundry services, food shopping, meal preparation, and running errands

Usually not covered by Medicare or Medicaid

In most states, no licensing or certification is required for the individual providing the care.

Homemaker Services

Provide older adults with inexpensive, nutritious meals at home or in group settings

Home-delivery programs such as Meals-on-Wheels deliver hot meals to the home once or twice a day, 5 days a week, and can accommodate special diets

Congregate meal sites provide meals in group settings such as senior centers, churches, synagogues, schools, and senior housing.

Nutrition Services

Community based transportation services for disabled older adults through public or private agencies with minimal fee

Transportation Services

Provide regular phone contact to older persons who live alone or are alone during the day.

Visitors make home visits for the purpose of companionship, assistance with correspondence, and needs assessment.

These services are usually offered for a monthly fee.

Telephone Monitoring and Friendly Visitors

Home monitoring systems that allow older persons to obtain immediate assistance in emergent situations, such as after a fall or when suffering life-threatening symptoms

Small device worn on the body (encouraged to be a necklace) and, when triggered, will send an alarm to a central monitoring station which summons help

Can be purchased or leased for a monthly fee

Personal Emergency Response Systems (PERS)

Multiple health and social services delivered to recovering, chronically ill, or disabled individuals of all ages in their place of residence

Services are covered by Medicare, Medicaid, private insurance, managed care plans, and private pay.

Home Health Care

Have a skilled care need

Be homebound

Be unable to perform the skilled care alone and have no one in the home to provide care

Require only intermittent care

Specific criteria established for coverage by physician, home health agency, disciplines providing care, and other entities providing goods or services to the patient

Home Health Care Recipient Requirements

Home care

Proprietary agencies

Facility-based agencies

Visiting nurse associations

Types of Home Health Care Agencies

Individuals who at one time could be treated only in the hospital can now be managed at home.

Home care is less expensive than hospitalization in most cases.

People recover faster at home than in institutions

Hospital-acquired infections from exposure to multiple infectious processes are minimized in a person’s home.

Benefits of Home Care

Involves assisting older adults to remain in the home and avoid institutionalization by having available resources that are responsive to their needs

Screening for home care needs begins at the time of admission to a hospital to ensure adequate time to plan for continuity of care.

Facilitated by social worker or case manager

Continuity of Care

Nurse’s role—conduct initial evaluation visit, assesses the client’s physical, functional, emotional, socioeconomic, and environmental well-being and carries out various nursing interventions like wound care and patient teaching

Implementing the Plan of Treatment

Knows about acute and chronic disease processes and how they affect older adults

Knows about gerontology, pharmacokinetics, rehabilitation nursing, and principles and presentation of disease processes in older adults

Knows about learning principles and interpersonal communication techniques, aware of cultural differences

Coordinates care and knows that observations made must be acted on immediately

Characteristics of a Home Care Nurse

Hospice provides care and services to terminally ill persons and their families, which enable individuals to die in facilities or at home.

Care is designed to address the physical, emotional, psychological, and spiritual needs of dying persons and provide support services for their families.

Goal: provide comfort care, not a cure

Hospice is a specific type of palliative care.

Hospice

Is a broader concept: therapy aimed at relieving or reducing the intensity of uncomfortable symptoms; not aimed at producing a cure

Provided in settings outside a hospice program and currently not subject to the same regulations as hospice programs

Control of pain, other symptoms, and of psychological, social, and spiritual problems is paramount.

Goal is achievement of the best possible quality of life for clients and families.

Palliative Care

Interdisciplinary team members use their skills and expertise to meet the needs of dying persons and their families such as:

Teaching family and friends how to administer medications

Helping dying persons maintain as much mobility and activity as possible

Listening and responding to a dying person’s needs

Help is available 24 hours a day.

Hospice Services

Fully covered with Medicare Part A—eligible when meeting three conditions:

The patient is terminally ill and has a life expectancy of 6 months or less.

Care must be provided by hospice program vs. standard Medicare benefits.

Care must be provided by a Medicare-certified hospice program.

Covers pain and symptom-control medications for a terminal illness, and durable medical equipment needed

Hospice as a Medicare Benefit

A collection of health, personal, and social services provided over a prolonged period

Persons living in nursing facilities are called residents.

Settings may be categorized on a continuum according to the complexity of care provided and the amount of skilled care and services required.

All nursing facilities must function under the federal regulations set forth by Omnibus Budget Reconciliation Act (OBRA).

Long-Term Care

Residents have the right to autonomy and to be active participants and decision makers in their care and life in the institutional setting.

All departments within the nursing facility, including social services, activities, nursing, dietary, and maintenance, must share responsibility for ensuring the enforcement of resident rights.

Resident Rights a Nursing Facility

Interdisciplinary functional assessment of residents is the cornerstone of clinical practice.

Resident assessment instrument (RAI)—is completed for each resident on admission, annually, when a significant change of condition occurs

Minimum data set (MDS)—is a tool that includes a comprehensive assessment of residents

Resident assessment protocols (RAPs)

Resident Assessment

Skin and nail care programs are important to a resident’s overall health and quality of life.

Focused on prevention and treatment of skin problems

Development of pressure ulcers during a person’s stay in a nursing facility is considered an indicator of poor quality of care.

Most facilities require at least weekly monitoring by a registered nurse.

Skin Care Program

As functional dependence increases, incontinence increases

Has financial, physical, and psychosocial consequences

Physical consequences include skin breakdown, urinary tract infections, and an increased risk of falling and consequent hip fracture.

Psychologically distressing health problem; may lead to depression, decreased self-esteem, and social isolation

Incontinence

Nutritional status of older people is an important determinant of quality of life, morbidity, and mortality.

Meeting a resident’s nutritional needs requires involvement of the entire health care team.

Any weight loss or weight gain must be carefully monitored.

The reasons for the loss or gain and the interventions taken must be documented.

Nutrition

Nurses are responsible for monitoring the therapeutic effects, side effects, any allergic reactions to medication, and the clinical manifestations of polypharmacy.

Routine use of long-acting benzodiazepines, hypnotics, sedatives, anxiolytics, and antipsychotics has been curtailed since the enactment of OBRA.

Residents must be informed of medication changes.

Medications

OBRA mandates that facilities provide services directed at achieving the highest practicable level of physical, mental, and psychosocial well-being for residents.

Intensive rehabilitation programs are reimbursed through Medicare Part A.

Restorative nursing programs are reimbursed through Medicare Part B.

Facilities must provide the required rehabilitation services or obtain them from an outside source.

Rehabilitation

OBRA requires nursing facilities to have an infection control program designed to provide a safe, sanitary, and comfortable environment.

Purpose: prevent development and transmission of disease

Facilities must have policies and procedures for investigating, controlling, and preventing infections.

Infection Control

Behavioral problems may jeopardize the safety of the resident or other residents.

60% of nursing facility residents have some degree of cognitive deficit which frequently precipitate difficult behaviors.

Use of physical and chemical restraints is restricted.

Emphasis is placed on using behavioral interventions and environmental modifications.

Mental Health

Functional nursing

Team nursing

Primary team nursing

Nursing Care Delivery Systems

Attractive long-term care setting, placed between home care and the nursing facility in the continuum of long-term care

Regulations are minimal so there is diversity in the types of service delivery models, types of services offered, and the setting within which assisted living is provided.

Assisted Living Programs

Special care units specialized units for persons with Alzheimer’s disease and dementia.

Subacute care—persons are stable and no longer acutely ill but may require rehabilitation, intravenous medication therapy, parenteral nutrition, complex respiratory care, and wound management

Is a growing industry

Specialty Care Settings

Creativity in “everyday” nursing facilities

For example, dogs, cats, and other animals that can live in the facility and serve as loving companions to the residents.

Nurse practitioners in nursing facilities in collaboration with physicians have been shown to reduce emergency department transfers, hospital days, and subacute days.

Innovations in the Nursing Facility

Professional nurses play a dominant role in improving and transforming this practice setting.

Nurses can prepare themselves for this role thru increased education in gerontologic nursing, nursing administration, health care regulation, and public policy related to long-term care.

The Future of the Nursing Facility

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