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Regine C.

Sulib BSN-IV July , 2014

Elective 2 Tuesday 2:30 pm- 4:30 pm
Health Education in Chronic Illness
Cardiovascular System
Normal Changes
Heart becomes larger and occupies a greater amount of space within the chest.
Reduction in the amount of functional muscle mass of heart.
Decreased amount of blood that is pumped throughout the circulatory system.
More adventitious S4 heart sounds.
Premature contractions and arrhythmias.
Blood fl ow is slower (wounds heal slower and impacts medication metabolism and distribution).
Low diastolic pressure.
Increased pulse pressure.

Nursing Interventions
Can be cardiomyopathy, so refer for diagnostic tests.
Inform patient that exercise can ultimately reduce the strain on the heart.
Heart murmurs require further tests to determine its effect.
Fatigue, SOB, DOE, dizziness, chest pain, headache, sudden weight gain, or changes in cognitive function or
cognition requires full assessment.
Know that the time of effectiveness may take longer when giving meds.
Inform patient that low diastolic pressure is a risk for cerebrovascular accidents or strokes.
Inform patient that exercise lowers blood pressure.

Peripheral Vascular System
Normal changes
Increase in the peripheral vascular resistance (blood has a hard time returning to the heart and lungs).
Valves in the veins dont function efficiently and form (nonpathological) edema

Nursing interventions
Inform patient that age, diet, genetics, and lack of exercise can transform nonpathological to pathological
(atherosclerosis and arteriosclerosis), which can result in CVD.
Monitor older adults cholesterol levels with lowering agents to prevent atherosclerosis and arteriosclerosis.
Inform patient that exercise results in lower cholesterol levels.
Discuss the right medication, exercise program, and diet for the patient as a means to slow the progression of
cardiac changes.

Respiratory System

Normal Changes
Decreased vital respiratory capacity.
Lungs lose elasticity.
Loss of water and calcium in bones causes the thoracic cage to stiffen.
Decreased amount of cilia lining system.
Decreased cough reflex.

Nursing interventions
Note that auscultating sounds is difficult so it must be done on all lung fields in a quiet environment.
Inform that pollution and smoking worsens the cilia (try to help stop smoking by recommending behavioral
management classes, support groups/nicotine replacement therapies, antidepressant medications).
Tell patients that they are at risk for choking.
Make sure patients respiratory function is frequently assessed.
Encourage regular exercise

Integumentary System
Normal Changes
Skin becomes thinner and more fragile.
Skin is dry and loses elasticity (wrinkles).
Sweat glands lessen, which leads to less perspiration.
Subcutaneous fat and muscular layers begin to diminish; less padding, more easily bruised.
Skin tears.
Fingernails and toenails become thick and brittle.
Hair becomes gray, fine, and thin.
Facial hair on women.
Decreased body hair on men and women.

Nursing Interventions
Promote the use of sun block and tell patient to avoid overexposure.
Avoid the use of soaps that dry skin and use a lotion after baths.
Protect high-risk areas such as elbows and heels with padding.
Refer to a podiatrist.
Help older adult maintain personal appearance.
Dont force old patients to take a bath

Gastrointestinal System
Normal changes
Inflamed gums.
Periodontal disease.
Sensitive teeth.
Tooth loss.
Decreased peristalsis of esophagus.
Decreased gut motility, gastric acid production, and absorption of nutrients.
Difficulty eliminating wastes (constipation).
Involuntary leakage of liquid stool (fecal incontinence).

Nursing Intervention
Assess older adults ability to chew.
Refer older adult for further oral evaluation if necessary.
Assist older adults in making changes with their eating habits.
Assess nutritional health frequently.
Encourage older adult to drink water (1.5 L).
Add bulk and fiber to diet.
Promote exercise.
Enemas and laxative medications may be given in severe situations.
Diets high in fiber and bulk, adequate fluids, and exercise.
Bowel habit training (for cognitively impaired).
In severe cases, surgery may be appropriate

Urinary System
Normal changes
Kidneys experience a loss of nephrons and glomeruli.
Bladder tone and volume capacity decreases.
Incontinence (not a normal change, but occurs in response).

Nursing Intervention
Assess urinary incontinence.
Kegel exercises.
Voiding schedules (for cognitively impaired).

Musculoskeletal System
Normal Changes
Decrease in total muscle and bone mass.
Muscle units that combine to form muscle groups diminish.

Nursing Intervention
Encourage older adult to exercise regularly

Sexual/Reproductive System
Normal Changes
Decrease in testosterone in men, and estrogen, progesterone,and androgen in women.
Follicular depletion in the ovaries.
Natural breast tissue is replaced by fatty tissue.
Labia shrinks.
Decrease in vaginal lubrications and shortening and narrowing of the vagina.
Strength of orgasmic contraction diminishes, and orgasmic phase is decreased.
Increased length of time needed for erections and ejaculation.

Nursing Intervention
Help older adult feel comfortable when discussing sexuality.
Give vaginal lubricants to females.
Inform men to increase the time between erections.
Discuss use of oral erective agents.

Normal Changes
Visual acuity declines and increased sensitivity to light and glare
Ability of pupil to constrict in response to stimuli decreases.
Peripheral vision declines.
Lens of the eye often becomes yellow.
Arcus senilus.
Ears: Increased amount of hard cerumen.
Taste and smell: 30% of taste buds diminish.
Reduction in number of receptors, reduction in blood flow; results in a reduction in tactile and vibration sensations
ecreased sensitivity to warm or cold stimuli
Due to decline in many sensory organs, cognitive functioning, and bodily strength; results in reduced velocity and
accuracy and greater variability across individuals
Nursing Intervention
Make sure older adult has a baseline eye assessment early in older adulthood and follow up eye exams yearly.
Help older adult remove cerumen.
Obtain a thorough history of taste and smell sensations and a physical examination of the nose and mouth.
Obtain a thorough diet history.
Use normal tone of voice, never shout.
Guide them in their activities (walking )
Long patience in answering questions and for their slow movements

Neurological System
Normal changes
Total brain weight decreases.
Shift in the proportion of gray matter to white matter.
Loss of neurons.
Increase in the number of senile plaques.
Blood flow to the cerebrum decreases
Decline in information processing speed, divided attention, sustained attention, visual-spatial tasks, short-term
In general, older adults report levels of satisfaction that are similar to that of younger adults (depression)
Nursing Intervention
Help older adult maintain an active body and mind.
Encourage older adults to participate in cognitive activities.

Physical activity
Physical activity has a positive impact on health counseling but we dont know if counseling about exercise is
effective in helping people to begin exercising. The USPSTF found insufficient evidence to determine whether
encouraging or counseling patients to begin an exercise program actually led to improvements
in their level of physical activity. There is strong evidence to support the effectiveness of physical activity in reducing
morbidity and mortality from chronic illness.

Scientific evidence supports the effectiveness of moderate physical activity in:
Decreasing overall mortality
Decreasing coronary heart disease, the leading cause of death in the United States
Decreasing colon cancer
Decreasing incidence and improving management of diabetes mellitus
Decreasing incidence and improving management of hypertension
Decreasing obesity
Improving depression
Improving quality of life
Improving functional status
Decreasing falls and injury

Counseling clients with chronic illnesses about nutrition is beneficial. Information should be geared to the chronic
illness. The USPSTF found good evidence to support counseling interventions among adults at
risk for diet-related chronic disease. Interventions that have proven to stimulate healthy dietary changes combine
nutrition education with behavioral counseling.
General guidelines for dietary counseling include:
Limit alcohol to one drink a day for women, two daily for men.
Limit fat and cholesterol.
Maintain balanced caloric intake.
Ensure adequate daily calcium, especially for women.
Older adults should consume vitamin B12 in crystalline form, which can be derived from fortified cereals and
Older adults who have minimal exposure to sunlight or who have dark skin need supplemental vitamin D. Daily
vitamin D intake should be 400600 IU and can be derived from fortified foods or supplements.
Include adequate whole grains, fruits, and vegetables.
Drink adequate water

Annual flu vaccine. Pneumococcal vaccine once after age 65 and onetime revaccination for clients over age 75
whove not been vaccinated in 5 years Td vaccine every 10 years ( tetanus and Diphtheria ). Immunization are
important to preventing illness, hospitalization, and mortality in both community-dwelling and institutionalized elderly
Screening is effective in identifying depression and treatments are effective. . The USPSTF found good
evidence that screening effectively identifies depressed patients and that treatment of depression improves clinical
Insufficient evidence to support mass screening of elders for dementia, but good evidence to suggest screening to
follow up on family or clients concerns about memory loss. The USPSTF found the clinical evidence to be insufficient to
recommend screening for all elderly clients in a primary care setting. Most expert panels agree that clients who are
suspected of having cognitive impairment or whose families express concern about their cognitive functioning should
be screened.
Tobacco use
Screening is helpful in identifying tobacco use and counseling is effective in helping people quit smoking. The
USPSTF found good evidence that screening, brief behavioral counseling, and pharmacotherapy are effective in helping
clients to quit smoking and remain smoke-free after one year. There is good data to support that smoking cessation
lowers the risk for heart disease, stroke, and lung disease.
Falls can be prevented by medication monitoring, balance and and strengthening exercise programs, home
safety assessment and training, and medication monitoring and adjustment are recommended in order to reduce
fall risk.
Aspirin therapy
There is good evidence that aspirin decreases the incidence of CHD in adults who are at increased risk for heart
disease, but aspirin increases the incidence of gastrointestinal bleeding and hemorrhagic strokes. The USPSTF
concluded that evidence is strongest to support aspirin therapy in patients at high risk of CHD
Cerebrovascular disease
Insufficient evidence for use of carotid ultrasound to screen for carotid stenosis as a CVA risk factor.
Thyroid disease
There is insufficient evidence to recommend for or against screening based on limited evidence to establish health
risks of subclinical disease and due to the risks of treatment.
Screening is recommended for all women over 65. Osteoporosis is common in the elderly and is correlated
with fracture risk. There are good screening tests to diagnose osteoporosis and effective treatments for the disease
years of age.
Alcohol abuse
Screening is beneficial and treatment is effective. The USPSTF found good evidence that screening is beneficial in
identifying patients whose alcohol consumption patterns place them at risk for increased
morbidity and mortality, as well as good evidence that counseling about alcohol reduction can produce a sustained
benefit over a 6- to 12-month period
Elder abuse and neglect
Insufficient evidence to support mass screening based on insufficient research to support the use of any particular
screening tool, and lack of evidence to support that identification of risk changes outcomes.
Clues to abuse may include:
Good evidence to support that treatment and screening are effective. A simple blood test is a valid and reliable
method of diagnosing lipid abnormalities, and diet and drug therapies are effective remedies.
Good evidence to support that treatment and screening are effective. Can identify adults at increased
risk for cardiovascular disease due to high blood pressure. Treatment of hypertension substantially decreases the
incidence of cardiovascular disease.
Vision and hearing
The task force recommends screening older adults for hearing loss by asking them about their hearing, counseling
them about hearing aids, and referring them to specialists when abnormalities are detected. Glaucoma testing by an
ophthalmologist is recommended for adults at risk of developing glaucoma.
Prostate cancer
There is insufficient evidence to recommend screening based on inconclusive evidence that screening with DRE and
PSA improves health outcomes. Men with a life expectancy of less than 10 years are unlikely to benefit from prostate
Breast cancer
There is fair evidence to support benefit from breast cancer screening for older women by mammogram every 1 to
2 years. There is no age at which screening should be discontinued, but the task force agrees that screening would have
no benefit when life expectancy is significantly limited by dementia or other serious, lifelimiting chronic illnesses.
Colorectal cancer
The task force strongly recommends colorectal screening by FOBT, FOBT _ sigmoidoscopy, or sigmoidoscopy alone
for clients with average risk of developing colorectal cancer. The task force was unable to determine whether the
increased sensitivity of colonoscopy compared with the other screening methods outweighed the costs, risks, and
inconvenience of the procedure.

Four of the most important lessons patients with chronic diseases need to understand are the following:
Their illness is serious. There are still patients out there who believe they have the not-so-serious kind of
diabetes. If they don't believe it is a problem, they will never make changes to improve their health.
Their condition is essentially self-managed. Every decision patients make throughout the day, from what they
eat to whether they walk or ride the bus, has an influence on their health. Communicate to patients that they are the
most important individuals in managing their illnesses.
They have options. There is rarely one perfect way to treat a condition. In the case of diabetes, for example,
patients can be treated through diet and exercise, oral medication, insulin and so on. Patients need to understand the
different treatment options available and should be encouraged to look at the personal costs and benefits of each.
Only the patient can decide if the benefits are greater than the costs.
They can change their behavior. Rarely do patients leave the doctor's office and immediately enact whatever
change was recommended. The reality is that it often has to be spread out into a series of steps. Teach patients that
significant behavioral changes can be made by setting goals, taking that first step and figuring out what you learn about
yourself along the way

Behavioral Management in Chronically Illness
Coping: Constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands
that are appraised as taxing or exceeding the resources of the person (Eiser, 1993, p.94)
Two ways of coping:
Attempting to change or control some aspect of the individual or environment (problem focused)
By managing or regulating the negative emotions associated with the stressor (emotion-focused)
Coping Interventions
Control negative feelings and remain positive
Maintain satisfactory self-image
Preserve good relationships
Prepare for uncertain future
Individual counseling is another tool that can help chronically ill patients copes with challenges. While support
groups are best at building community, they do not allow for the privacy necessary in dealing with sensitive issues.
Individual counseling and family counseling can help expose sensitive emotions and relationship issues, and can help a
person or family group move toward resolution of these challenges. It is important that both the patient and the family
receive the individualized help they need.
Establish a support networks of family and friends who want to help
Surround yourself with things that inspire joy, happiness and encouragement (favorite books, inspirational
sayings, family photo)
Educate yourself about your disease or condition using credible, current sources, knowledge helps dispel fear
and anxiety
Take care of yourself by eating right, maintaining your appearance, getting plenty of sleep, excercising and
having fun
Have a routine and do something- accomplish a task, however small- every day to lend stability and consistency
to your life
Positive thoughts and acceptance of diagnosis can help ward off depression and other potential emotional and
physical complications that are common in chronically ill patients.

Coping Strategies
At some point in the cycle of your illness you come to recognize the chronicity of your symptoms and
the realization that you must learn to cope long term with the effects and changes to yourself and life
overall. A significant objective in the management of your condition is to regain a sense of personal
control over your self and your life. The following areas can assist in the achievement of this goal.
Educate yourself: Information is power and educating yourself during this time is an important way to
take charge of your situation. This is a time to take full responsibility for the management of your health
and it means knowing your choices and making decisions for your care.
Environmental changes: Learning ways to organize your home and work setting to make the tasks of
daily living easier is a practical way to feel in charge.
Access resources: Review financial issues, home care, insurance and disability claims, support groups,
educational seminars, books, audiotapes.
Symptom management: Follow through on recommended treatment, investigate additional or
alternate forms of treatment, be informed about medication, and decrease overuse of narcotics and
self-medicating (alcohol or substance abuse), proper nutrition, recommended exercise program.
Body Awareness: Become familiar with activities that trigger symptoms, learn the art of pacing; that
is, discovering what your body tells you about where its limits are. Be willing to gently challenge your
perceived limitations because there is also a tendency to protect in an attempt to avoid flare-ups. You
will need to regularly test your own limits to assess where you are at.
Communication: It is important for self-management to have the skills that effectively communicate
your needs to others. These people may be health care professionals, insurance representatives,
friends, family and significant others.
Re-examine roles and responsibilities: The need to be able to assert oneself is necessary in order to
successfully redefine boundaries and limits on what you need and what you can do.
Value clarification: Evaluate what is important to you in this moment and feel good about honoring
that. Recognize where and how you use your energy; emotionally and physically and decide if how you
are doing so supports your well-being.
Goal-setting: Providing structure to your day through some basic planning and setting realistic goals
contributes to a greater sense of purpose.
Rebuild confidence: As you find ways to empower yourself ensure that you acknowledge and validate
all your successes; big and small. Reinforce the ways that you are still able versus emphasizing how
you feel dis-abled.
Challenge Negative Thought Patterns and Reframing: We are what we think. This is perhaps one of
the most important coping skills to learn in order to successfully manage and transcend the impact of
chronic illness. Changing your perspective has profound consequences to your emotional well-being,
which in turn affects your body in a positive way as well.
Attention-Control: This is a self-management technique that teaches you to deliberately shift attention
from one thing to another. It includes distraction away from your symptoms by engaging in alternate
and positive activities. Learning to distract yourself internally is also a successful way to lead your mind
away from pain and other symptoms
Identify Stressors and Relax: Stress worsens the experience of symptoms and leads to increased
tension which negatively impacts the body. Learning deep breathing methods, full body relaxation,
meditation, yoga, tai chi and other ways to relax the body are good for your overall state of well-being.
Discover new interests: Finding new activities through which you can experience pleasure is important
to successful coping. Find ways to make yourself laugh; since humor is healing.
Identify and Resolve Emotions: Emotions from the past and present may wash over you daily. Getting
professional assistance to work through these complex reactions is imperative to your state of wellness.
Since the mind and body are interconnected, internalizing emotions has a negative impact on the body.
We do not come into this life prepared to handle the challenges of an illness and yet we are extremely
harsh on ourselves for the emotions that we naturally feel as a result. It is important to learn to let go of
blame, self-punishment and have compassion for yourself and your body.
Letting Go: The capacity to truly transcend your illness and empower you toward a feeling of inner
peace requires the difficult task of letting-go. Recognizing where your attitudes and behaviors may be
fostering dependence, resistance and self-sabotage is important to being able to let go. Acceptance that
one must relinquish the old definition of self and life prior to becoming ill allows an opening to redefine
and create new meaning and purpose beyond your illness

Social Support System and Family in Chronic Illness
Seeking spiritual support
Establish a support networks of family and friends who want to help
Surround yourself with things that inspire joy, happiness and encouragement (favorite books, inspirational sayings,
family photo)
Support groups are one of the best avenues for help
Patient and the family must cope with the fear of an unknown and unknowable future. It is all too clear that the
comfortable patterns of the past have been shattered. It is not clear at all what may lie ahead.
In the isolation stage open communications are vital. Blame must not play a part. Talking about feelings is very
important. Communication and sharing are ways to break the isolation
Emphasize family strengths
Draw out family expectations of client and others
Assist in the reintegration of their roles
Validate the unpredictability, frustration, etc.
Differentiate between wants and needs in order to avoid disappointment and complaints
Caregivers need a break! Encourage them to compromise on certain aspects of managing the house
Families need help re-managing money
Facilitate caregivers perceptions of respite as a reasonable and appropriate action, not personal failure

Issues and Trends in Chronic Care
Common Chronic Illnesses
Cystic fibrosis
Spina bifida
Congenital heart disease
Sickle cell disease
Muscular Dystrophy
Neurological Disease
Kidney Disease
50% of the population have at least one chronic illness
Approximately 30% of adults between 18 and 44 years of age have a chronic illness.
As of 2012, about half of all adults117 million peoplehave one or more chronic health conditions. One of four
adults has two or more chronic health conditions
Biggest Worries About Having A Chronic Illness (Age 50 +)
1. Losing Independence
2. Being a Burden to Family or Friends
3. Not Being Able to Afford Needed Medical Care
4. Significantly reduced productivity
5. Living with less income
6. Accomplishing less
7. Spending more time in bed-sick
8. Having poor mental Health
Elder mistreatment impacts the psychological domain of health for older adults. It is estimated that approximately 1
million cases of elder mistreatment (EM) occur each year. However, this number is likely a severe underestimation, as
elder abuse is frequently not reported for several reasons. Victims may fear retaliation, feel shame, or have a desire or
need to protect the abuser and lack of mandatory universal reporting laws is another reason. Elder mistreatment can be
defined of acts of commission (intentional infliction of harm), or acts of omission (harm occurring through neglect) by a

Types of abuse include physical and psychological abuse and neglect and financial abuse.
Physical abuse may involve intentionally causing pain or injuring older adults, while psychological abuse involves
threatening, insulting, or socially isolating the older adult.
Physical and psychological neglect are often the most challenging forms of elder mistreatment to assess
because of the associated decline in physical and cognitive functioning common in these victims
Neglect implies a failure to perform an obligation and, therefore, raises questions regarding whether a family
does have an obligation to provide care for an older adult. It is important to assess whether the caregiver is
purposefully neglecting the older adult victim or is simply not physically or cognitively capable of caring for this
Active physical neglect arises from the purposeful withholding of necessities
Passive neglect results from the caregivers inability to identify the older adults needs or to
perform the tasks essential to meet the older adults needs.
Financial abuse may occur when the older adults funds, property, or assets are used for wrongful purposes, and
sexual abuse involves the sexual assault or rape of an older adult.
Characteristics that increase risks for caregivers to abuse an older adult include
a. substance abuse
b. mental illness
c. lack of knowledge or experience with care giving
d. financial stressors
e. history of abuse as a child
f. lack of outside interests and involvement
g. extreme life stressors
h. aggressive and unsympathetic personality
i. unrealistic expectations of the situation
The nurse should be alert to signs and symptoms of possible elder mistreatment, which may include:
a. patterns of unexplained injuries
b. indication that the older adult is fearful of their caregiver
c. anger or indifference by the caregiver toward the individual
d. excessive concern by the caregiver regarding the individuals assets
e. injuries or unexplained infections present in the clients genital region
f. severe, unexplained dehydration or malnutrition, hypo- or hyperthermia related to environmental exposure
g. poor hygiene of the client
h. Unexplained management of medication.

Pain is the major physical issue for older adults and those who care for them. Flaherty (2007) reports that 25% to 50% of
community-dwelling older adults and 45% to 80% of nursing home residents experience untreated pain. Marcus (2004)
reports that there are many poor consequences of pain. These include depression, decreased socialization, sleep
disturbances, impaired functional ability, and increased health care utilization and costs.
Despite the great prevalence and impact of pain on older adults, there are many barriers that prevent success in this
area. Some nurses believe that pain is a natural and expected part of aging, and this remains one of the most prevalent
myths and a barrier to appropriate pain assessment and management. Other barriers include older adults hesitancy to
report pain, because they may believe that it is an expected part of aging and nothing can be done for it, or they simply
may be afraid to bother their nurse.

Grandparenting, due to the longer lifespan of women, it has been revealed that grandchildren are more likely to know
their grandmothers than their grandfathers. Reasons for this increase in grandparents raising grandchildren often stem
from child mistreatment and neglect and may include:
a. impairment of the biological parents through substance abuse,
b. rise in rates of teen pregnancy
c. presence of acquired immunodeficiency syndrome (AIDS)
d. incarceration
e. mental illness
f. emotional problems
g. Premature parental death
Grandparents who raise grandchildren are at higher risk for health problems than older adults who do not serve in this
care giving role. Moreover, grandparents raising grandchildren may also have financial problems and other care giving
responsibilities (e.g., Spouse). Grandparents caring for grandchildren are more likely to have (a) higher rates of chronic
diseases, (b) female gender, (c) high rates of unemployment, and (d) less than a 12th-grade education.

Spirituality, It is of great importance that nurses understand that spirituality and the practice of religion vary greatly
among older adults. While the process of aging often fosters a search for the meaning of life, not all older adults search in
the same way. The nurse is likely to practice a religion different from the older adult, so it is important that the nurse
does not impose their personal beliefs and religious views on their patients. The nurse must be open and understanding,
allowing the older adult to pursue spirituality in their own unique way. The presence of spirituality has been associated
with relief from physical, mental, and addictive disorders and with enhanced quality of life and survival. Older adults who
engage in religious and spiritual practice often cope better psychologically and have better physical health than those
who dont

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(2010). http://www.cdc.gov/chronicdisease/overview/index.htm