APPENDIX A American Nurses' Association Standards of Gerontological Practice*

Standard I Data collected about the status of the older adult are systematically and continuously. The data are accessible, commu• nicated and recorded.

Standard II Nursing diagnoses are derived from the identified normal responses of the individual to and the data collected about the health status of the older adult.

Standard III A plan of nursing care is developed in conjunction with the older adult and/or significant others, that includes goals derived from the .

Standard IV The plan of nursing care includes priorities and prescribed nursing approaches, and measures to achieve the goals derived from the nursing diagnosis.

• American Nurses' Association. 1976. Standards of Practice. Kansas City, MO: American Nurses' Association.

165 Standard V The plan of care is implemented, using appropriate nursing actions.

Standard VI The older adult and/or significant other(s) participate in determin• ing the process attained in the achievement of established goals.

Standard Vll The older adult and/or significant others participate in the ongoing process of assessment, the setting of new goals, the reordering of priorities, the revision of plans for nursing care, and the initiation of new nursing actions.

166 APPENDIX B Approved nursing diagnoses (North American Nursing Diagnosis Association-NANDA) 1990

Activity intolerance Activity intolerance, potential Adjustment, impaired Airway clearance, ineffective Altered nutrition: more than body requirements Altered nutrition: less than body requirements Altered nutrition: potential for more than body requirements Altered protection Anxiety Aspiration, potential for Body image disturbance Body temperature, altered: potential Bowel incontinence Breast feeding, effective Breast feeding, ineffective Breathing pattern, ineffective Cardiac output, decreased Communication, impaired: verbal Constipation Constipation, colonic Constipation, perceived Coping, defensive Coping, family: potential for growth Coping, ineffective family: compromised Coping, ineffective family: disabling Coping, ineffective individual Decisional conflict (specify)

167 Denial, ineffective Diarrhoea Disuse syndrome, potential for Diversional activity deficit Dysreflexia Family processes, altered Fatigue Fear Fluid volume deficit Fluid volume deficit, potential Fluid volume excess Gas exchange, impaired Grieving, anticipatory Grieving, dysfunctional Growth and development, altered Health maintenance, altered Health-seeking behaviours (specify) Home maintenance management, impaired Hopelessness Hyperthermia Hypothermia Infection, potential for Injury, potential for Knowledge deficit (specify) Mobility, impaired physical Noncompliance (specify) Oral mucous membrane, altered Pain Pain, chronic Parental role conflict Parenting, altered Parenting, altered: potential Personal identity disturbance Poisoning, potential for Post-trauma response Powerlessness Rape-trauma syndrome Rape-trauma syndrome: compound reaction Rape-trauma syndrome: silent reaction Role-performance, altered Self-care deficit: bathing/hygiene Self-care deficit: dressing/grooming 168 Self-care deficit: feeding Self-care deficit: toileting Self-esteem disturbance Self-esteem, low: chronic Self-esteem, low: situational Sensory-perceptual alterations: visual, auditory, kinaesthetic, gustatory, tactile, auditory (specify) Sexual dysfunction Sexuality, altered patterns Skin integrity, impaired Skin integrity, impaired: potential Sleep pattern disturbance Social interaction, impaired Social isolation Spiritual distress (distress of the human spirit) Suffocation, potential for Swallowing, impaired Thermoregulation, impaired Thought processes, altered Tissue integrity, impaired Tissue perfusion, altered: renal, cerebral, cardiopulmonary, gastro• intestinal, peripheral (specify type) Trauma, potential for Unilateral neglect Urinary elimination, altered Urinary incontinence, functional Urinary incontinence, reflex Urinary incontinence, stress Urinary incontinence, total Urinary incontinence, urge Urinary retention Violence, potential for: self-directed or directed at others

169 NOTES AND REFERENCES

Introduction I Bury, M. and Holme, A. 1991. Life after Ninety. London: Routledge, I. 2 Coni, N., Davison, W. and Webster, S. 1988. Lecture Notes on (3rd edn). Oxford: Blackwell Scientific Publications, 19. 3 Guardian, 8 May 1991 (Society Today). 4 Project 2000: A new Preparation for Practice. 1986. London: UKCC.

Chapter 1 I For a discussion of various classifications of ADLs, see Twining, C. 1991. Quality of Life: Assessment and Improvement. In Denham, M. J. (ed.), Care of the Long-Stay Elderly Patient (2nd edn). London: Chapman and Hall. 2 Sendell, B. and Hunt, P. 1987. Nursing the Adult with a Specific Physiological Disturbance (2nd edn). London: Macmillan. 3 Booth, B. 1990. Does it really matter at that age? Nursing Times 86(3), 5(}-2.

Chapter 2 I Morton, P. G. (ed.) 1990. Health Assessment (Nurse's Clinical Guide). Springhouse, Pa.: Springhouse Corporation. 2 Eliopoulos, C. 1984. Health Assessment of the Older Adult. Reading, Mass.: Addison-Wesley. 3 Coni, N., Davison, W. and Webster, S. 1988. Lecture Notes on Geriatrics (3rd edn). Oxford: Blackwell Scientific Publications, 19. 4 Storer, R. 1985. The gastrointestinal system - the oral tissues. In Brocklehurst, J. C. (ed.) 1985. Textbook of Geriatric Medicine and (3rd edn). Edinburgh: Churchill Livingstone. 5 Thurlbeck, W. M. 1981. The ageing lung. In Scadding, J. G. and Cumming, G. (eds), Scientific Foundations of Respiratory Medicine. London: Heinemann. 6 Armstrong, M. and Cleary, M. 1982. Physiology of Ageing, Part II. Villanova, Pa.: ProScientia. 7 Interpreting arterial blood gases. 1980. American Journal of Nursing 80 (12), 2197-2201.

170 8 Carotenuto, R. and Bullock, J. 1980. Physical Assessment of Gerontological Client. Philadelphia, Pa.: Davis. 9 Malasanos, L., Barkauskas, V., Moss M. and Stoltenberg-Allen, K. 1981. Health Assessment. St. Louis, Miss.: Mosby. 10 Walsh, M. and Ford, P. 1989. Nursing Rituals: Research and Rational Actions. Oxford: Heinemann Nursing. 11 Caird, F. 1., Dall, J. L. C. and Williams, B. 0. 1985. The cardiovascular system. In Brocklehurst, J. C. (ed.), Textbook of Geriatric Medicine. 12 Matteson, M.A. and McConnell, E. S. (eds) 1988. Gerontological Nursing: Concepts and Practice. Philadelphia, Pa.: W. B. Saunders. 13 Dayan, A. D. and Lewis, P. D. 1985. The central nervous system - neuropathology of ageing. In Brocklehurst, J. C. (ed.), Textbook of Geriatric Medicine. 14 Alcott, D. 1990. Normal ageing. In Stokes, G. and Goudie, F., Working with . Bicester, Oxon.: Winslow Press. I 5 An excellent text, which covers the subject of memory and the older person comprehensively, is by Twining, C. 1991. The Memory Handbook. Bicester, Oxon.: Winslow Press. 16 Estimates vary between texts, from definite percentages to general statements, hedged with qualifications. For example, in Martin, A. and Gambrill, E. C. 1986. Geriatrics. Lancaster: MTP Press, the authors state that 'psychiatric disorders' in the over-65s is 'around 5%', rising to 'over 20%' by age 80; but Post reviews a large number of surveys, without giving any definitive estimates, in Post, F. 1985. The central nervous system - the emotional disorders. In Brocklehurst J. C. (ed.) Textbook of Geriatric Medicine. 17 Malasanos et al. 1981. Health Assessment. 18 Goudie, F. 1990. Intellectual and behavioural assessment. In Stokes, G. and Goudie, F. Working with Dementia. 19 Pathy, M.S. J. 1985. The central nervous system- clinical presentation and management of neurological disorders in . In Brocklehurst, J. c. (ed.). 20 Ibid. 21 Blacklock, N.J. 1985. The genitourinary system - the prostate. In Brocklehurst, J. C. (ed.) Textbook of Geriatric Medicine. 22 In the editor's opinion, the best book on this subject to have been published to date is by Gibson, H. B. 1992. The Emotional and Sexual Lives of Older People- A Manual for Professionals. London: Chapman and Hall. 23 Bellack, J. and Bamford, P. 1984. : A Multi• dimensional Approach. Monterey, Calif.: Wadsworth Health Science Division. 24 Sundwall, D., Rolando, J. and Thome, G. 1981. Endocrine and metabolic function. In O'Hara-Devereaux, M., Andrus, L. and Scott, C. (eds) 1981. Eldercare. New York: Grune and Stratton. 25 For a comprehensive discussion of theories of ageing, see ch. 5 of Matteston, M.A. and McConnell, E. S. 1988. Gerontological Nursing. 26 Davies, I. 1985. Biology of ageing - general principles. In Brocklehurst, J. C. Textbook of Geriatric Medicine.

171 Part 0 Introduction Nursing Times commissioned two articles in 1992 about the possible use of nursing diagnoses in this country: one for, and one against. They are: Booth, B. One step forward ... and Webb, C. ... Or two steps back? Nursing Times 88 (7), 32-4. 2 Orem, D. 1985. Nursing: Concepts of Practice (3rd edn). New York: McGraw-Hill. 3 Marks-Maran, D. 1983. Can nurses diagnose? Nursing Times 19 (4), 68-9. 4 Roper, N., Logan, W. W. and Tierney, A.J. 1985. The Elements of Nursing. Edinburgh: Churchill Livingstone. 5 Miller, J., Steele, K. and Boisen, A. 1987. The impact of nursing diagnoses in a long-term setting. Nursing Clinics of North America 22(4), 905--15. 6 Field, P. A. 1990. The impact of on the clinical decision• making process. In lsmeurt, R. L., Arnold, E. N. and Benner Carson, V. (eds) 1990. Concepts Fundamental to Nursing. Springhouse, Pa.: Springhouse Corporation. 7 Omaha VNA Problem Classification Scheme. 1991. In Carlson, J. H., Craft, C. A., McGuire, A. D. and Pop kess-Vawter, S. Nursing Diagnosis: A Case Study Approach. Philadelphia, Pa.: Saunders. 8 The North American Nursing Diagnosis Association (NANDA) has been working towards a standardisation of nursing diagnosis categories since 1973. 9 Although it is not easy reading, the text by Carlson et a/. mentioned in Note 7 above is.a comprehensive guide to the whole subject. A good introduction to the use of nursing diagnoses in elderly care is: Maas, M. Buckwalter, K.C. and Hardy, M. (eds) 1991. Nursing Diagnoses and Interventions for the Elderly. Redwood City, Calif.: Addison-Wesley Nursing.

Chapter 3 I Schoenbaum, S.C., McNeil, B.J. and Kavet, J. 1976. The swine• influenza decision. The New England Journal of Medicine 295, 759---{;5. 2 Fox, R. A. 1985. Immunology of ageing. In Brocklehurst, J. C. (ed.): Textbook of Geriatric Medicine and Gerontology. Edinburgh: Churchill Livingstone, 96--7. 3 Parkin, D. 1985. Revise Nursing RGN. London: Letts, 15. 4 A clearly-written, step-by-step guide to relaxation techniques can be found in King, P. 1990. Living with stroke. Manchester University Press, ch. 7. 5 Freeman, E. 1985. The respiratory system. In Brocklehurst, J. C. Textbook of Geriatric Medicine. 15Q-l.

Chapter 4 I Booth, B. 1990. Aggressive treatment and the elderly. Nursing Standard 4(26), 29-31.

172 2 Eliopolous, C. Gerontological Nursing. New York: Harper & Row, 143. 3 Kintzel, K. Advanced Concepts in Clinical Nursing (2nd ed.). Philadelphia, Pa.: Lippincott, 503. 4 Howser, D. 1976. Ice water for MI patients! Why not? American Journal of Nursing, 16 (3), 432-4. 5 Carotenuto, R. and Bullock, J. 1980. Physical Assessment of the Geronto/ogic Client. Philadelphia, Pa.: Davis, 95. 6 Hooker, S. 1990. Caring for Elderly People (2nd edn). London: TavistockfRoutledge, 113. 7 British Medical Association/Royal Pharmaceutical Society of Great Britain: (1991). British National Formulary.

Chapter 5 I Martin, A. and Gambrill, E. C. Geriatrics. Lancaster: MTP Press, 97-8. 2 Norton, C. 1991. Eliminating. In Redfern, S. J. (ed.): Nursing Elderly People (2nd edn). Edinburgh: Churchill Livingstone, 193. 3 Ibid. 195.

Chapter 6 I Walsh, M. and Ford, P. 1989. Nursing: Rituals, Research and Rational Actions. Oxford: Heinemann Nursing, 113. 2 Morgan, W. Thomas, C. and Schuster, M. 1981. Gastrointestinal system. In O'Hara-Devereaux, M. (eds), Eldercare. New York: Grune and Stratton, 203. 3 Brick and Amory (1950), cited in Dymock, I. W. 1985. The gastro• intestinal system - the upper gastrointestinal tract. In Brocklehurst, J. C. Textbook of Geriatric Medicine, 512. 4 Billings, D. and Stokes, L. 1982. Medical- . StLouis,: Miss. Mosby, 977. 5 Hyams, D. E. and Fox, R. A. 1985. The gastrointestinal system - the liver and biliary system. In Brocklehurst, J. C. Textbook of Geriatric Medicine, 516. 6 Morgan et a/, 1981. Gastrointestinal System, 202. 7 Mager-O'Connor, E. 1984. How to identify and remove faecal impactions. Geriatric Nursing, S (3), 158-61.

Chapter 7 Exton-Smith, A. N. 1985. The musculoskeletal system - bone ageing and metabolic . In Brocklehurst J. C. Textbook of Geriatric Medicine, 160. 2 Richards, M. 1982. Osteoporosis. Geriatric Nursing, 3 (2), 98-102. 3 Rossman, I. 1981. Human ageing changes. In Burnside, I. M. (ed.), Nursing and the Aged (2nd edn) New York: McGraw-Hill, 39. 4 Keene, J. and Anderson, C. Hip fractures in the elderly. Journal of the American Medical Association, 248 (5), 564--7. 173 Chapter 8 I Atkinson, D. (director of the Chest, Heart and Stroke Association), in Swaffield, L. 1990. Stroke - the Complete Guide to Recovery and Rehabilitation. Wellingborough: Thorsons, 6. 2 Williams, M. 1987. Aphasia. In Gregory, R. L. (ed.); The Oxford Companion to the Mind. Oxford University Press. 3 WHO. 1971. Cerebrovascular : Prevention, Treatment and Rehabilitation. WHO Technical Report Series, no. 469. 4 WilJiams, H. McDonald, E., Daggett, M., Schut, B. and Buckwalter, K. 1983. Treating dysphagia. Journal of Gerontological Nursing, 9(12), 638-47. 5 Andrews, K. 1987. Rehabilitation of the Older Adult. London: Edward Arnold, 305--6. 6 Farber, S. 1982. Neurorehabilitation: A Multisensory Approach. Philadelphia, Pa.: Saunders, 258. 7 WilJiams, M. 1987. Aphasia. 8 Rosenzweig, M. R. and Leiman, A. L. 1982. Physiological Psychology. Lexington, Mass. DC Heath, 652. 9 Weitzel, E. A. 1991. Unilateral neglect. In Maas, M. Buckwalter, K. C. and Hardy, M. (eds); Nursing Diagnoses and Interventions for the Elderly. Redwood City, Cal.: Addison-Wesley Nursing, 393. 10 Sagar, H. 1991. Parkinson's Di.sease. London: Optima, 36. II Ibid., 71. 12 Ibid., 56. 13 Wolanin, M. and PhilJips. L. 1981. Confusion: Prevention and Care. St Louis, Miss.: Mosby. 14 Riordan, J. and Whitmore, B. 1990. Living with Dementia. Manchester University Press, 136. 15 Ibid., 135. 16 Neshkes, R. E. and Jarvik, L. F. 1985. The central nervous system• dementia and delirium in old age. In Brocklehurst, J. C. Textbook of Geriatric Medicine, 312-3.

Chapter 9 I Podlone, M. and Millican, C. 1981. Neurology. In O'Hara-Devereaux eta/. Eldercare, 118.

Chapter 10 I Sundwall, D. Rolando, J. and Thorn, G. 1981. Endocrine and metabolic systems. In O'Hara-Devereaux eta/. Eldercare. 142. 2 Ibid., 139-40. 3 Schteingart, D. 1978. Endocrinology and metabolism: principles of pathophysiology. In Price, S. and Wilson, L. (eds), Pathophysiology: Clinical Concepts of Disease Processes. New York: McGraw-Hill, 699. 4 Doenges, M. Jeffries, W. and Moorhouse, F. 1984. Nursing Care Plans: Nursing Diagnoses in Planning Patient Care. Philadelphia, Pa,: Davis, 469.

174 Chapter 11 Norton, D. Exton-Smith, A. N. and McLaren, R. 1975. An Investigation of Geriatric Nursing Problems in Hospital (1962; reprinted and reissued by Churchill Livingstone). 2 Waterlow, J. 1985. Risk assessment card. Nursing Times, 81(48), 4<)..!55. 3 Byrne, N. and Feld, M. 1984. Preventing and treating decubitus ulcers. Nursing 84 14 (4), 5~. 4 The Code of Professional Conduct for Nurses, Midwives and Hea/Jh Visitors. 1983. London: United Kingdom Central Control for Nurses, Midwives and Health Visitors. 5 Bates, B. 1983. A Guide to Physical Examination (3rd edn). New York: McGraw-Hill), 318-9. 6 Ibid. Chapter 12 Donne, John, Meditation, XVII. The whole of it reads: 'No man is an Island, entire of itself; every man is a piece of the Continent, a part of thl' main; if a clod be washed away by the sea, Europe is the less, as well as if a promontory were, as well as if a manor of thy friends or of thine own were; any man's death diminishes me, because I am involved in Mankind; and therefore never send to know for whom the bell tolls; it tolls for thee.' Some sociologists have used thousands of words to say the same thing, only not as clearly. 2 Riordan, J. and Whitmore, B. 1990. Living with Dementia. Manchester University Press, 2. 3 Haywood, S. Standards of institutional care for the elderly. In Denham, M. J.(ed.), Care of the Long-stay Elderly Patient (2nd edn). London: Chapman and Hall, 12-13. 4 If the reader does not believe in self-fulfilling prophecies, or is unfamiliar with the term, it is strongly recommended that they read Rosenthal and Jacobson, 1968 'Self-Fulfilling Prophecies in the Classroom: Teachers' Expectations as Unintended Determinants of Pupils' Intellectual Competence', in Deutsch eta/. (eds). Social Class. Race, and Psychological Development (New York: Holt, Rinehart and Winston, 219-54). Very briefly, they told teachers that certain pupils (secretly selected at random) would shine in the forthcoming academic year; and every one of their 'predictions' came true. This has a lot of implications for nurses working with the elderly, because we often make assumptions about how well people are going to respond to treatment, within minutes of meeting them; in the author's experience, this is particularly true of 'confused' people, whom we may unconsciously 'write ofr as candidates for progress. 5 Welford, A. T. 1987. Ageing- memory and learning. In Gregory, R. L. (ed.); The Oxford Companion to the Mind. Oxford University Press. 14. 6 Twining, C. The Memory Handbook. Bicester: Winslow Press 9-10. 7 Sourander, L. B. and Rowe, J. W. 1985. The ageing kidney. In Brocklehurst, J. C. (ed.); Textbook of Geriatric Medicine and Gerontology (3rd edn). Edinburgh: Churchill Livingstone, 608-10. 8 'The Seven Ages of Man', from Shakespeare's As You Like It.

175 9 The entry for 'psychiatry' in R. L. Gregory, 1987. Oxford Companion to the Mind, 649, says that it emerged as a branch of medicine in Britain during the first half of the nineteenth century; some textbooks treat anything before 1880 as being too primitive to deserve the name, whilst still others do not consider that there was any such speciality until this century. 10 Pitt, B. 1982. Psychogeriatrics - An Introduction to the Psychiatry of Old Age (2nd edn). Edinburgh: Churchill Livingstone, I. II Murphy, E. 1986. Dementia and Mental Illness in the Old. London: Papermac Health, 169. 12 Sagar, H. 1991. Parkinson's Disease. London: Optima 49. 13 ZangwiU, 0. L. 1987. Delirium. In Gregory, R. L. Oxford Companion to the Mind. Oxford University Press. 184. 14 Rabins, P. V. 1985. The reversible . In Arie, T. (ed.), Recent Advances in Psychogeriatrics: no. I. Edinburgh: Churchill Livingstone, 93. 15 Riordan. S. and Whitmore, B. 1990. Living with Dementia, 2. 16 Stokes, G. and Holden, U. 1990. Dementia: causes and clinical syndromes. In Stokes, G. and Goudie, F. (eds), Working with dementia. Bicester: Winslow Press, 16. 17 Dartington, T. The Limits of Altruism: Elderly Mentally Infirm People as a Test Case for Collaboration. London: King Edward's Hospital Fund for London, 27-72. 18 Riordan. S. and Whitmore, B. 1990. Living with Dementia, 14. 19 This survey, conducted by the Health Services Management Centre, showed NHS and private beds for the elderly to total 54 775 and 56 779 respectively. Cited in Haywood, S. 1991. Standards of institutional care, 13. 20 Dartington, T. 1986. The Limits of Altruism, particularly the introduction. 21 Summaries of these can be found in: Post, F. 1985. The emotional disorders, in Brocklehurst, J. C. Textbook of Geriatric Medicine, 330; Henderson, A. S. 1989. Epidemiology of mental illness, in Hafner, H. Moschel, G. and Sartorius, N. (eds), Mental Health in the Elderly: A Review of the Present State of Research. Berlin: Springer-Verlag, 29 (this book is available in Britain); and Post, F. and Shulman, K. 1985. New views on old age affective disorders, in: Arie, T. Recent Advances, 119--20. 22 Gianturco, D. T. and Busse, E. W. 1978. Psychiatric problems encountered during a long-term study of ageing volunteers. In Isaac, A. D. and Post, F. (eds): Studies in General Psychiatry. Chichester: John Wiley and Sons 1-16. 23 Gurland eta/, cited in Post, F. The emotional disorders, 330. 24 Blazer and Williams, 1985. The emotional disorders. 'Dysphoric syndrome' certainly sounds better than the term used previously for sub-acute depression in the elderly, which was 'senile demoralisation'. 25 Evans, J. G. Physical factors in mental health in the elderly: gerontological and internal medical aspects. In Hafner et a/, Mental Health, 51. 26 Post, F. 1985. The emotional disorders. 120.

176 27 A very welcome backlash to negative attitudes towards ageing came from many authors in the 1970s and 1980s, with books like Alex Comfort's A Good Age, Muriel Skeet's The Third Age, and others, none of which appear on recommended reading lists with the frequency one might hope for. 28 Seligman, M. 1975. Helplessness. San Francisco: Freman. 29 Norman, I. J. 1991. Depression in old age. In Redfern, S. J. (ed.): Nursing Elderly People (2nd edn) Edinburgh: Churchill Livingstone 366--8. 30 Murphy, E. 1986. Dementia, 166. 31 Post, F. Paranoid, schizophrenic-like and schizophrenic states in the aged. In Birren, J. E. and Sloane, R. B. (eds), Handbook of Mental Health and Ageing. Englewood Cliffs, NJ: Prentice-Hall, 591--615. 32 For a thoughtful discussion of this issue, see Gilhooly, M. L. M. Ethical and legal issues in therapy with the elderly, in Hanley, I. and Gilhooly, M. L. M. (eds): Psychological Therapies for the Elderly. London: Croom Helm, 173-97, but particularly the section on 'consent', 178-82. 33 'Neurosis', in Gregory, R. L. 1987. The Oxford Companion, 549. 34 Pitt, B. 1982. Psychogeriatrics. 110. 35 ibid. 36 'Diogenes' syndrome' is marked by gross self-neglect and a tendency towards hoarding; any reader who has met someone with this condition will know what a convincing defence of their lifestyle the 'sufferer' can put up. (See Clark, A. N. G, Mankikar, G. D, and Gray, I. 1975. Diogenes syndrome: a clinical study of gross neglect in old age. Lancet i, 366--73.) 37 Pitt, B. 1982. Psychogeriatrics: an introduction to the psychiatry of old age (2nd edn). Edinburgh: Churchill Livingstone. 38 'DSM-III' is the usual way texts refer to: American Psychiatric Association. 1980. Diagnostic and Statistical Manual of Mental Disorders (3rd ed.). Washington DC: APA. 39 McConnell, E. S. 1988. Nursing diagnoses related to psychosocial alterations. In: Matteson, M. A, and McConnell, E. S. Gerontological Nursing: Concepts and Practice. Philadelphia, Pa. WB Saunders, 529-86.

Chapter 13 DHSS. 1979. Nutrition and health in old age. Report on Health and Social Subjects, No.l6. London: HMSO. 2 Pritiken, N. and Cisney. 1986. Dietary recommendations for older Americans. In Dychtwald, K. (ed.), Wei/ness and Health Promotion for the Elderly. Rockville, MD. Aspen Systems. 3 Hooker, S. 1990. Caring for Elderly People (3rd edn). London: Routledge. 4 Brereton, P. J. 1991. Nutritional care of the long-stay patient. In Denham, M. J. (ed. ), Care of the long-stay elderly patient (2nd edn). London: Chapman and Hall. 5 Trollinger, J. Dowhler, D. and Calin, A. 1981 Musculoskeletal system. In O'Hara-Devereaux et a/. (eds), Eldercare. New York: Grune and Stratton.

177 6 For a summary of fairly recent thought on the subject, see Exton• Smith, A. N. 1985. The musculoskeletal system - bone ageing and metabolic disease. In Brocklehurst, J. C. Textbook of Geriatric Medicine and Gerontology (3rd edn). Edinburgh: Churchill Livingstone. 7 Yen, P. K. 1986. Ten tips for teaching. Geriatric Nursing [US] 7(2), 112. 8 Bailey, L. B. and Certa, J. J. 1986. Diagnoses and treatment of nutritional disorders in older patients. Geriatrics, 39 (8), 67-74. 9 Dickman, S. R. 1979. Nutritional needs and effects of poor nutrition in elderly persons. In Reinhart, A.M. et a/. (eds), Current Practice in Geronto/ogic Nursing. StLouis: Mosby. 10 Moehrlin, B., Wolanin, M. 0. and Burnside, I. M. 1981. Nutrition and the elderly. In Burnside, I. M. (ed.), Nursing and the Aged. New York: McGraw-Hill. II Brereton, P.J. 1991. Nutritional care. 109-25.

Chapter 14 I Christopher, M.A. 1986. Home care for the elderly. Nursing 86, 16 (7), 50-5. 2 For a thoughtful discussion of the pros and cons of restricting a confused person's ability to leave the house, see Chapter 6 of Riordan, J. and Whitmore, B. 1990. Living with Dementia. Manchester University Press.

Chapter 15 'Hughes, R.' 1990. An odyssey through the Eighties. Nursing Times 86 (26), 28-32. 2 McGuire, A. D. 1991. The genesis and nature of nursing diagnoses. In Carlson, J. H., Craft, C. McGuire, A. and Popkess-Vawter, S. (eds); Nursing Diagnosis: A Case Study Approach. Philadelphia: WB Saunders, 3-20. 3 Several authors, including Bloch, D. Roy, C. Mundinger, M. and Jauron, G. have used this 'five-step' definition of the . For further discussion, see the references passim in McGuire 1991, the genesis and nature of nursing diagnoses. 4 Gordon, M. 1982. Nursing Diagnosis: Process and Application. New York: McGraw-Hill. 5 Each architect of a nursing model has something to say about setting goals; for a selection of examples, using different models, see Easterbrook, J. (ed.) 1987. Elderly Care - Towards . London: Hodder and Stoughton. 6 Bahr, R. T. and Gress, L. 1985. The 24-hour cycle: Rhythms of healthy sleep. Journal of Gerontological Nursing, 11(4), 14-17. 7 Lyon, B. 1983. Nursing Practice: An Exemplification of the Statutory Definition. Birmingham, Ala.: Pathway Press. 8 Schmadl, J. 1979. Quality assurance: examination of the concept. Nursing Outlook 27(7), 462-46~. 9 Andrews, K. 1987. Rehabilitation of the Older Adult. London: Edward Arnold.

178 10 Evers, H. K. 1982. Multidisciplinary teams in geriatric wards: myth or reality? Journal of Advanced Nursing, 6, 205--14. II Hewner, S. 1986. Bringing home the . Journal of Gerontological Nursing, 12(2), 29-35.

179 INDEX

Abbreviated Mental Test Score 33 American Nurses' Association see also mental status standards of practice 165----{) questionnaire anaemias 56, 63--5 abdomen iron deficiency 64, 131 age changes 31 pernicious 64-5 physical assessment 31, 40 angina pectoris 56 acoustic nerve 34 nursing diagnoses and see also hearing interventions 61-2 activities of daily living anxiety 128 (ADLs) 170 case study 161 and Alzheimer's disease 98 and emphysema 53, 54 assessment 5, 7, II, 19 and myocardial infarction 57 and osteoarthritis 84 nursing diagnoses 167 activity reduction of 54 and Alzheimer's disease 99-100 aphasia 87, 98 assessment 18-19 expressive and receptive 88 acute brain syndrome 95----{) apraxia 98 causes 9 5----{) assessment 145 nursing diagnoses and initial interview 5-23 interventions 96 physical assessment address, forms of 4 worksheet 36-42, 151 admission to hospital see assistive devices hospitalisation assessment 14 affective illness 124--6 and CVA 90 ageing 103, 137 and loss 118, 124-5 and home environment 138, negative expectations 116-17, 139, 142 125----{), 129, 175, 177 and rheumatoid arthritis 84 physical changes 26-43 atherosclerosis 56 agnosia 98 attitudes AIDS-related dementia 97 positive of carers 5 airway clearance 50, 51, 53, 54, to ageing 116-17, 125----{), 129, 62-3 175, 177 case study 162 audiometric testing 103, 104 and CV A 88, 89 auscultation 26 nursing diagnoses 167 of chest 29 alcohol usage 13 Alzheimer's disease 97 Babinski sign 34 assessment 98 behaviour disorders 127 case study 122-3, 156-8 bladder see incontinence; urinary nursing diagnoses and tract interventions 98-101 blood pressure 30, 60 signs and symptoms 98 see also hypertension stages of 97-101 body image and CV A 89

180 Bouchard's nodes 32 nursing diagnoses and bowel elimination interventions 71-2 and Alzheimer's disease 99 cellular ageing 36 assessment 18, 41 cerebrovascular accident 88-92 and CVA 88 and environment 136 nursing diagnoses 167 example of evaluation 147-8 see also constipation; potential nursing incontinence diagnoses 88-92 bradykinesia 92 rehabilitation 88 brain, age changes 32-3 signs and symptoms 87 see also acute brain syndrome; cerumen cerebrovascular; chronic age changes 26--7 brain syndrome; normal and hearing loss 103 pressure hydrocephalus; chest, physical assessment 29, 30, organic brain diseases 39-40 brain failure see chronic brain chiropody 106 syndrome chronic brain syndrome 97-101 breasts, assessment 28, 40 symptoms 97 breathing, assessment 20 Chvostek's sign 34 Byrne, N. 110 circulatory problems assessment 19 caffeine and incontinence 68 client participation 146, 166 calcium requirements 131 cognitive status assessment 15 calorie requirements 130 communication 150 carbohydrate requirement 130, and acute brain syndrome 96 131 and Alzheimer's disease 98, 99 cardiovascular system between nurses 146 age changes 29-31 and CVA 88, 91 nursing interventions 56 and hearing loss I 03--4 physical assessment 40 impaired 4, 128 problems 56--65 nursing diagnoses 167 care and Parkinson's disease 93, 94 audits of 148 community numbers in long-term 116 care 122, 123, 150 see also care plans; nursing discharge into 3, 7 diagnoses; nursing process and information collection 10 care plans 3, 48, 116 liaison letter 3 American Standards 165--6 loans 141-2 and discharge of patients 3, 4 community nurse and environment 138 and care plans 4 formulating and following case study 160--4 up 145--52 role of 152 as goal-orientated 147, 150 see also home care holistic 120 confusional states and hospital admission 4 and home care 141 multidisciplinary 149-50 and paranoia 126 case studies 153--64 see also delirium; dementia cataracts 26, 102 congestive cardiac failure 58-9 catheterisation 70, 151 potential nursing diagnoses and indwelling 71-2 interventions 58-9

181 congestive cardiac failure (cont.) and CVA 90 signs 58 and nutrition 133 constipation 79-80 depression 118, 124--6, 176 and Alzheimer's disease 99, causes 124 100-1 and CVA 88 case study 161 incidence of 124, 125 and CV A 88, 90 diabetes mellitus 105--6 and diverticulitis 76 case study 153--5 and haemorrhoids 78 potential nursing diagnoses and nursing diagnoses 79, 167 interventions 106-7 nursing interventions 79-80 symptoms 105 and Parkinson's disease 92, 93, types of 105 94, 95 diagnoses, nursing 47-9 prevention of 52, 79 taxonomy of 48 contact lenses I 02 diet see nutrition continuing care settings digitalis preparations 63 and environment 135 see also medication and nutrition 132 Diogenes syndrome 127, 177 coping discharge 3, 7 assessment II, 15 and information 3 ineffectual 128 planning 116 nursing diagnoses 167 disease and ageing 36, 47 counselling diuretics 59 on nutrition 134 diverticulitis 76-7 and Parkinson's disease 95 nursing diagnoses and cranial nerves assessment 33--4, 42 interventions 76-7 Creutzfeld-Jakob's disease 97 Donne, John 115, 175 cultural factors 6, 22 douching 73 and nutrition 6, 134 DSM-III 129, 177 CV A see cerebrovascular accident Dupuytren's contractures 32 dying, case study 158-9 Dartington, T. 124 see also loss death, attitudes towards 22 dysphasia 87 decubitus ulcers 109-11 dysphoric syndrome 124, 176 see also pressure sores degenerative changes 36 delirium 120--1 ears 26, 27 dementia 121--4 physical assessment 38 delirium 120--1 see also hearing diagnosing 121 elimination patterns incidence of 116, 117, 121-2 assessment 17-18 multi-infarct 97 Eliopoulos, C. 26 wandering 141 emotional illness 33, 176 see also chronic brain syndrome; emotional status assessment 15 wandering emphysema 50, 53--4 demographic changes 123 case study 162 dental hygiene 27 nursing diagnoses and dentition, case study 163 interventions 53--4 dentures 27, 39 endocrine system 35--6 and anaemias 63, 64 enema 79, 80

182 environment fever and acute brain syndrome 96 and gallbladder disease 77 aesthetic stimulation 137 and rheumatoid arthritis 84 and Alzheimer's disease 99, and urinary tract infections 69, 100, 101 70 case study 162 financial status facilitative 135-42 assessment 1(}...-11, 23 home 138--42, 152 and nutrition 132, 133, 134 andincontinence 67 fluid intake and individual needs 136, 137 and Alzheimer's disease 99, 100 privacy 136, 138 case study 162, 164 and visual loss 91-2, 103 and CCF 58, 59 see also home environment and constipation 79 epistaxis 60 and CVA 88, 89 ethnic groups and diabetus mellitus 106 dietary practices 6, 134 and diverticulitis 76 and information collection 6, 8 and incontinence 67-8 examination, physical and prostatic hypertrophy 70 nurses' role 24, 25 requirements 131 strategies of 26 and urinary tract infections 69 exercises 90 foot care see feet musculoskeletal problems 82--4 footboards 91 and Parkinson's disease 94 Ford, P. 75 expanded role 24--5 friends, role in assessment 20 expressive aphasia 88 extended role 24 eyes 26 gallbladder disease, nursing and hyperthyroidism I 08 diagnoses and physical assessment 37-8 interventions 77 see also vision gastrointestinal problems 74--80 genitourinary system 35 facial nerves 34 see also female reproductive; faecal impaction 79--80 male reproductive; urinary family tract assessment 20 glaucoma I 02 care by 122--4 glossitis 65 and care planning 116 glossopharyngeal nerve 34 and information collection 4, Gordon, M. 146 8-9, 13 graphic ability 33 nursing diagnoses 168 grieving see loss and psychosocial disorders 128 Griffiths Report 150 fat requirement 130, 131 fear see anxiety feet haemorrhoids 63 assessment 28, 41 nursing diagnoses and care and diabetus mellitus 106 interventions 78 Feld, M. llO hallucinations 95, 96, 98 female reproductive system hands, examination of 32 assessment 21-2, 35, 41 head, physical assessment 26-8, problems 72-3 37-9

183 Heaf test 55 hygiene practices and Alzheimer's health history 3, ll-15 disease 98 hearing hyperglycaemia 105, 106 age changes 26--7 hypertension 56, 59-{)() assessment 14, 34 and blood pressure 30 environmental nursing diagnoses and considerations 137 interventions 60 nursing diagnoses and hyperthermia, nursing intervention 103--4 diagnoses 168 problems 103--4 hyperthyroidism 107-8 heart nursing diagnoses and age changes 29-31 interventions 108 murmurs 30 hypoglossal nerve 34 see also cardiovascular system hypoglycaemia 105, 106 heart attack see myocardial hypothermia infarction and hypothyroidism 107 heartburn 75 nursing diagnoses 168 Heberden's nodes 32, 83 hypothyroidism, nursing diagnoses help, summoning 139 and interventions l 07 hemianopia 88 hypoxia 95 and environment 136 Hewner, S. 152 immune system, age changes 35--6 hiatal hernia, nursing diagnoses and imrnunisations 50 interventions 75 incontinence 66--9 hip fractures, nursing diagnoses and and Alzheimer's disease 98, 99, interventions 85--6 101 holistic care 115--16 bladder retraining 68--9, 72 home care bowel 167 case study 160--4 causes 66, 67 nursing diagnoses 168 and CVA 90 and physical assessment 25 and normal pressure role of nurse 15~2. 152 hydrocephalus home environment 138--42, 152 101 assessment 20, 142 and Parkinson's disease 93, 94 bathroom 1~1 potential nursing illumination 140 diagnoses 66--7 and information collection 9 potential nursing locks 141 interventions 67-9 and safety 138, 139--41 independence of client 150 home help 140 and osteoarthritis 83 case study 164 indwelling catheters 71-2 hormone disorders 105 infection hospitalloans 141-2 and catheterisation 71 hospitalisation and confusional state 121 admission 7; and nursing diagnoses 168 assessment 25 and Parkinson's disease 93, 94 and nutrition 132 influenza 50 housing and home care 140 information collection Huntington's chorea 97 American Standards 165 hydration see fluid intake assessment document 5--7, 151

184 as counter-productive lipofuscin 36 procedure 23 liver health history 5--7 age changes 31 initial interview 3-7 physical assessment 41 sources of 3-4 loan, community 141-2 types of 4--5 locks, home environment 141 inhalers 54 loneliness injury, physical assessment 20 and Alzheimer's disease 99, 100 home care: case study 161-2 and anaemias 65 and nutrition 132, 133 and angina pectoris 61 long-term care case study 157, 163 and environment 135--8 and hypertension 60 numbers in 116 and Lenegre's disease 62 loss see also musculoskeletal system and ageing 118, 124-5 insomnia and CCF 58 case study 163 insulin, age changes 35 and nutrition 133 integumentary system, physical lungs, assessment 29, 39-40 assessment 28, 37 see also respiratory system see also skin intelligence, age changes 33 McConnell, E.S. 129 interview, initial 3-23 male reproductive system, duration 6, 23 assessment 22, 35, 41 home care 150-1 Mantoux test 55 see also information collection Meals on Wheels 132, 140 intestinal tract 31 case study 154, 164 iron deficiency anaemia 64, 131 medical jargon 4 isolation and nutrition 132, 133 medication see also social isolation case study 161 and diabetus mellitus 105, 106 jargon, medical 4 digitalis peparations 63 joint contractures 85, 86 and information collection 5, and CVA 88, 91 13 and mental dysfunction 119 ketoacidosis I 05 and nutrition 133 kidneys 66 over-the-counter 5--6 age changes 35 Parkinson's disease 93, 95 knowledge deficit 128 and rheumatoid arthritis 85 case study 154, 159 and xerostomia 74 gynaecological examinations 72 mental confusion nursing diagnoses 168 and anaemias 63 and CCF 58 learned helplessness 125 see also confusional states Lenegre's disease 62-3 mental disorders, nursing diagnoses and classification 119-20 interventions 62-3 Mental Health Act (1983) 126 symptoms 62 mental health see psychosocial leucorrhoea 72 aspects of care levodopa therapy 93 mental status questionnaire 33, 96 'Lifeline' 139 case study 157

185 metabolic disorders 105--8 organic brain diseases; metabolism assessment 15, 16 Parkinson's disease mirror sign 98 neuroses, defined 126-7 mobility non-steroidal anti-inflammatory assessment 18-19 drugs 85 changes in 65 normal pressure and CV A 88, 89, 90 hydrocephalus 101 and hip fractures 85, 86 North American Nursing nursing diagnoses 168 Diagnosis Association see and nutrition 132 NANDA and osteoarthritis 83-4 Norton, D. 109 and Parkinson's disease 93, 94 nose, assessment of 27, 38 Morton, P.G. 25 NSAIDs 85 motor functions assessment 41, 42 nurse, role of 24 multidisciplinary care expanded 24 plans 149-50 extended 24 muscle function 32 extinction 24, 25 muscle rigidity and Parkinson's nursing diagnoses 47-9, 145-6, disease 92, 94 172 musculoskeletal system case studies 153, 154-64 age changes 32, 178 classification 146 physical assessment 41 identification of goals 146, 178 problems 81-6 identification of see also hip fractures; interventions 146 osteoarthritis; osteoporosis; NANDA see separate entry rheumatoid arthritis taxonomy 48, 118-19 myocardial infarction 56-8, 121 see also care plans; nursing nursing priorities 57 process potential nursing nursing homes interventions 57-8 attitudes to 152 myxoedema coma I 07 case study 156-7 and environment 135 private 122, 176 nails, assessment 37 nursing process 115, 178 see also toenails and client participation 146 NANDA 167-8, 172 evaluation 146-9; case taxonomy 49, 172 studies 153-5, 156, 158, National Health Service continuing- 160 care beds 122, 176 home care 150-2 nebulisers 54 intervention case neck, assessment 26-8, 37, 39 studies 154-64 neglect, self- 127, 177 quality assurance 148-9 neurological system quality of care 146-7 age changes 32-5 stages 145, 146 disorders 88-1 0 I nutrition 74, 130-4 physical assessment 42 and Alzheimer's disease 99, 100 see also acute brain syndrome; and anaemias 63, 64, 65 cerebrovascular; chronic and angina pectoris 61 brain syndrome; normal assessment 5, 15--16, 133 pressure hydrocephalus; at-risk groups 133

186 and cardiovascular and hip fractures 85 problems 56 and hypertension 60 case study 156--7, 159--{i(), 162, and information collection 5 163 nursing diagnoses 168 and constipation 79 nursing interventions 52 and CV A 88, 89-90 and osteoarthritis 83 and diabetus mellitus 106 and osteoporosis 81, 82 and diverticulitis 77 and prostatic hypertrophy 70, fibre 131 71 and gallbladder disease 77 and rheumatoid arthritis 84 and hiatal hernia 75 and urinary tract infections 69 and hyperthyroidism l 08 and vaginitis 72 nursing diagnoses 167 palpation 26 and osteoporosis 81, 82 paranoid states 126 overweight 134 paraphrenia 126 and Parkinson's disease 93, 94 Parkinson's disease 92-5 and pneumonia 51-2 potential nursing diagnoses 93 promotion of 132-4 potential nursing psychosocial and cultural interventions 94--5 factors 134 signs of 92-3 requirements 130--l patches, nitrate 61, 62 and tuberculosis 55 pelvic examination, internal 35 see also fluid intake percussion 26 of chest 29 occupational therapist 138 periodontal disease 27, 74 Omaha VNA/PCS and nutrition 133 taxonomy 48-9 peripheral vascular disease 56 oral cavity 74--5 pernicious anaemia 64--5 age changes 27 personal hygiene hygiene and nutrition 133 and incontinence 68 physical assessment 38-9 and initial interview 5 organic brain diseases 95--101 personal space 136 diagnostic tests 95 personality disorders 127 orientation 96, 99 phenothiazines 93 case study 157 physical assessment osteoarthritis 81, 83-4 worksheet 36--42, 151 nursing diagnoses and Pick's disease 97 interventions 83-4 Pitt, B. 119,127 osteoporosis 81-2 plan of care see care plans and nutrition 81, 82 pneumonia 50--2 and physical injury 81, 82 and Parkinson's disease 93 over-the-counter medications 5--6 potential nursing diagnoses 50-I pain 57 potential nursing and angina pectoris 61 interventions 51-2 case study 158, 159 presbycusis 27, 103-4 and CCF 59 pressure area care 52 and diverticulitis 76 and CCF 59 and gallbladder disease 77 and hip fractures 86 and haemorrhoids 78 see also pressure sores

187 pressure sores 109-11 residential homes and case study 158, 159 environment 135 classification 110 see also nursing homes mattresses 109 respiratory system prevention 110 age changes 28-9 treatment 110 problems 50-5 privacy 136, 138 rest private nursing homes 122, 176 and angina pectoris 61 prolapse 73 and emphysema 54 prostatic examination 35 and pneumonia 52 prostatic hypertrophy 66, 70-1 and prostatic hypertrophy 70 nursing diagnoses and restraints 178 interventions 70-1 undesirability of 96, 136 symptoms 70 resuscitation 58 protein requirement 130, 131 rheumatoid arthritis, nursing psychiatry 176 diagnoses and see also psychosocial disorders interventions 84-5 psychogeriatrics 119 Rinne test 27 psychosis 127 role of nurse see nurse, role of psychosocial aspects of care 115--29 psychosocial disorders safety 135 classification 119-20 case study 157 holistic approach 129 home environment 138, incidence of 171 139-41; case study 160, nursing diagnoses 128-9 163--4 see also depression; neuroses; self-perception see self-concept paranoid states self-care practices pulse rate, assessment 40 and CVA 89 deficit and nursing quality assurance 148-9 diagnoses 168-9 and information collection 5 self-concept 128 reality orientation 96, 99 assessment 20-1 receptive aphasia 88 ano incontinence 67' 68 rectum, physical assessment 41 nursing diagnoses 168, 169 reflexes 42 and Parkinson's disease 93, 95 relatives Seligman, M. 125 case study 158 sensation assessment 34-5 and information 4 sensory changes see hearing; relaxation techniques 60, 163, 172 vision religion sexuality 116 and assessment 22 age changes 35 and information collection 6, 8 assessment 7, 21, 23 relocation confusion 137 nursing diagnoses 169 reminiscence therapy I 00 skin care practices, assessment 17 case study 157 skin integrity reproductive system see female and angina pectoris 61 reproductive system; male assessment 15, 17, 28, 37 reproductive system case study 155, 159

188 and CCF 59 tactile sensation 14, 137-8 and CVA 89, 91 taste assessment 14 and diabetus mellitus 106 taxonomy of nursing diagnosis 48, disorders I 09--12 118-19 example of evaluation 147 teeth 74 and gallbladder disease 77 age changes 27 and hip fractures 85 physical assessment 39 nursing diagnoses 169 telephone and home care 139 and Parkinson's disease 93, 95 territory of clients 136, 137 and vaginitis 72 thyroid gland 27, 39 see also decubitus ulcers; pressure toenails sores; stasis ulcers assessment 28, 41 sleep pattern 51, 70, 128 and diabetus mellitus 106 and Alzheimer's disease 99, toilets 52 100 and home care 140 assessment 18, 19-20 seats 136 case study 163 touch 137-8 example of evaluation 148 assessment 14 nursing diagnoses 169 transfer of patient 3, 7 see also rest and environment 136-7 smell relocation confusion 137 age changes 27, 34 to another ward 3 assessment 14 transient ischaemic attack 87-8 smoke alarms 139 trigeminal and facial nerves 34 smoking 13 tuberculosis 50, 54-5 case study 161, 162 nursing diagnoses and social isolation 128 interventions 55 nursing diagnoses 169 and nutrition 132, 133 UKCC 25 speech ulcers see decubitus ulcers; stasis and Alzheimer's disease 98 ulcers assessment 14, 33 United States and CVA 91 community nurse 152 and Parkinson's disease 92 defining dementia 121 spinal accessory nerve 34 emotional illness studies 33 spinal column evaluation of nursing 146-7 age changes 32 hip fractures 85 assessment 29, 41 nurses' role 24, 25 and osteoporosis 82 Standards of Gerontological spiritual distress 128 Nursing Practice 165-6 nursing diagnoses 169 urinary tract stasis ulcers 111-12 age changes 35 stomach examination 31 assessment of patterns 17-18 stress bladder infections 69-70 and ageing 36, 118 incontinence 66-9; nursing assessment II, 13, 14 diagnoses 169 stroke see cerebrovascular infections 66, 69-70; nursing accident diagnoses and suicide 126 interventions 69-70; syphilis-related dementia 97 symptoms 69

189 urinary tract, infections (cont.) and nutrition 132 problems 66--72; and problems 102-3 CVA 90; and Parkinson's vitamin and mineral disease 92, 93, 94 requirements 131 testing urine 67 voluntary sector 138-9, 142 vaginitis 72 values and beliefs 20, 22 Walsh, M. 75 Vaughan, Barbara 24-5 wandering 178 violence 128 and acute brain syndrome 95, and Alzheimer's disease 99, 101 96 nursing diagnoses 169 jingle bells 141 vision Waterlow, J. 109 age changes 26, 34 Weber test 27 assessment 14, 37--8 wound care see decubitus ulcers; and CVA 88, 89, 91-2 pressure sores; skin integrity; and environment 136, 137, 138 stasis ulcers nursing diagnoses and intervention 102-3 Xerostomia 74-5

190