When a sick person goes to the doctor he hopes to be cured. If he recovers he is happy, the doctor is satisfied, and the nurse knows that a job has been well done. If, however, the patient has an incurable illness, the doctor has a problem, the patient presents difficulties and the nurse must adjust to imperfect results. Nursing care is, therefore, more complicated, particularly if the person is not able to maintain the sort of wellness that he had before he became sicker or if he has an incurable or terminal illness. The older patient is often the recipient of therapeutic measures which do not cure him but which increase the level of wellness. The term, taken from Dunn, indicates that every part of the organism rarely, if ever, enjoys perfect physical and emotional health. Most commonly there are some cells of the body which are functioning perfectly while others may be functioning at an average level of wellness, and still others are actually losing their functions and are dying.
Because the health problem is not always black and white and because there are levels of wellness, diagnosis of elderly patients by the doctor is often more complex. The trouble may stem from normal biological aging or it may be an abnormal process. The patient's complaints may be dismissed by such remarks as "You aren't so young as you used to be..." This, undoubtedly, is a true statement but it doesn't cure and comfort the patient. Extensive research is needed to determine the difference between normal aging and disease.
According to Dr. Aldred Worcester's aphorism, "There are no diseases peculiar to old age or very few from which it is exempt." Ailments of older persons are no different, initially, than ailments of younger persons. Correspondingly, therapeutic measures are much the same for patients of all age groups. In the first, or first-aid, phase of nursing, the nurse performs many nursing activities and may devote the majority of her time to following the medical regime She acts in response to the physician's order. It is agreed that the first-aid plan includes not only medication, but intimate bodily care and emotional support. Whether the person is a newborn infant or an octogenarian, antibiotics are administered for infection. Most all postoperative patients are given intravenous fluids. If a bone is fractured, the fracture is reduced. If the patient has pain, he is given analgesics; if he sleeps less, hypnotics. All persons do not respond in the same manner to these various treatments, but the great majority of them do. With an older person, however, the situation is potentially less perfunctory and the number of persons who do not respond favorably to illness is potentially greater. Nursing care calls for recognition that older persons are more vulnerable to the stresses of living. They are often in a socially precarious state which, among other things, diminished sight or hearing can accentuate. They are in a physically fragile state as evidenced by increased susceptibility to infection and trauma, and they are in an emotionally labile state where overreactions can be precipitated by gradual or abrupt losses and deprivations. The nurse can be instrumental in helping the older person maintain his equilibrium, or homeostasis, so that his vulnerability can be minimized and his strength increased.
This second phase of nursing is a latent-potential phase. The nurse's responsibilities include health maintenance and promotion. This, like phase three, in which a nurse cares for the chronically or terminally ill patient, is often prolonged. Phase two is when the real difference begins.
The skills which the nurse knows so well and are needed for the first-aid phase are not needed as much as in the second phase. The nurse feels that she is not doing enough to keep the patient in the hospital. The nurse begins to feel that she is not needed It is in the second phase, when the doctor's orders lessen and the patient begins to need less intensive nursing care, that the nurse begins to start the agitations and rumors. She may ask, "When is Mr. S. going home?" The nurse, disturbed, feels that Mr. S. should be going home. Consequently, Mr, S. feels that he is not performing according to the nurse's expectations of him.
Most of us would agree that persons of all age groups need to be treated as individuals, need to be loved, and to love. Universally, man needs recognition of what he is and what he can do, needs to feel useful, needs new experience, needs to play. But when we bring these generalities into a specific focus for a particular age group, there are a great many differences of opinion. An older person may be easily miscast in a role he does not want. A gray-haired person may not want to be called Grandma or Grandpa or John or May by one who is not related to him or her. Such presumptions are often an infringement. Witness, too, the stare of disbelief, amazement, condemnation, and even dismay when a person 65 or older announces that he is getting married. The rustles of opinion deny his privilege of being loved. If a child lacks encouragement it is considered with serious misgiving, but unless an older person has the talent of a Grandma Moses he is often overlooked Millions of dollars go into the manufacture of toys and games for children, but how many games calling for imagination or skill are oriented to the aged or the sedentary adult? The nurse, busy with her profession and her home-making, may find it incredible that a patient can find no useful occupation. A patient allowed to do something helpful for a nurse may be greatly benefited.
Why do we need to be reminded of these factors in caring for the aged? Perhaps because "age" in our society has neither the importance nor the status of "youth." In cultures such as the Chinese, or in religious faiths such as Judaism, elderly persons enjoy prestige and self-esteem, which helps them and their families feel that it is "all right to be old." Unfortunately, most American families today do not feel this way. In pioneer days the place of the elderly in the family structure and his living arrangements in the family home gave meaning and usefulness to the elderly. Today, where small homes with increasing numbers of children make living arrangements difficult, fewer elderly persons live with their families. The living arrangements are one thing but the real issue many times is more precisely what to do with the elderly person rather than the question of domicile. Because the family does not know what to do with him and he does not know what to do with the family, the nurse has the care of an increasing number of elderly persons in the hospital and/or nursing home. Many of these people could live in their families' homes if they were socially acceptable to the family. It is this inacceptibility which prompts the family to relinquish responsibility for an elderly person after he has been hospitalized. He may have no inhibitions about exposing himself, may use vile language, may be unable to see or hear well, may drool or be incontinent. The nurse's daily help with this "naked behavior" may encourage the septuagenarian or octogenarian to live a little more fully and to become more socially acceptable.
The older patient or person makes the nurse realize that she cannot solve all the problems of normal and abnormal life processes. Aging, a natural and normal process, begins when we are born and continues at different paces until every part of us dies. At birth the placenta, which has been the source of nutrient for the fetus, is no longer needed and is cast off as useless. In the adult old red blood cells and white cells are cast off by the body since these are no longer needed when they age. Likewise, excess fingernails are superfluous growth. These are "normal processes" which most people do not think about much or even have control over. They do not bother the nurse. She cannot prevent them from occurring. The real reason that these aging processes do not affect us as persons seems to be that they do not affect the way we look or feel or the kind of work which we can do. What does it matter if we lose a red or white aging blood cell every day providing, of course, that such a loss is within normal limits? Who even knows about it? In the first place, no one can see the loss of such cells. Husbands or wives do not get upset with an aging spouse because of it. But let a woman lose her hair or discover a new wrinkle, and the problem is attacked with greater defense than is presently being assembled in current military conflicts. At once, cosmetics, creams, and lotions may become the most important thing in her life.
A nurse, looking at an older patient, may see herself growing older. If she sees her own parents or grandparents in the bed or wheelchair, she may not be able to help the patient. The problem may seem so huge that her own contribution appears ridiculously small. Defeated, she runs the other way. She conceives of age as an end to life (and the age varies with each individual); small wonder that she feels inadequate and frustrated. If she has a role model where growing old is a treat instead of a treatment, she will be intrigued with how to help older people.
In our youth-centered culture, it is not only unacceptable but it is considered improvident and impractical even to become older. America is a young country, and the emphasis is on the vigorous and the hopeful. Parents, understandably, want their children to have fuller, richer lives than their own. Therefore the chain of action is perpetuated from generation to generation, with emphasis on building the youngster to develop his potential to the fullest extent. We are more aware or concerned about what youth can learn to do than what older adults can do, and yet interesting studies could be done on the influence of a knowledgeable oldster on youth. It is as though a person who did not learn to do everything before he is thirty cannot learn to do it afterwards. I have heard nurses in their late thirties say, "I cannot learn to play the piano; I am too old." This is, of course, a ridiculous assumption. It is the sort of thinking which leads us to fall into the emotional trap of considering our older patients as "too old to do this or that," because it is the way we look at it and it may be the way that they look at it. This produces a static situation where neither patient nor nurse move.
If the nurse creates a feeling toward the patient that he can do rather than approaching the situation negatively, the results can be quite exciting. Also, the patient's family may have established such a role for the patient so that the patient has given up fighting for his right to be able to do many things. Patients who are in this environment can profit by entering a dynamic nursing home environment. It is very exciting for patient, nurse, and family to see the growth and development possible with the adoption of a positive attitude.
The nurse who encourages grayhaired ailing Mrs. X to quilt may find Mrs. X less obstreperous. Miss Y, who has always had a yen to paint, may spend her last days more quickly and more peacefully if she is painting a picture. Reading or playing checkers may help shape the day for the sedentary or incapacitated Helping the patient to eat better, to go to the bathroom, or to dress better may interest him in tomorrow as well as in today. I believe that patients who are interested in life live longer. Certainly they enjoy living more.
The third phase of nursing, like the second phase, is more rewarding if it is positive and creative. It also involves the recognition that a complete cure for the patient is not possible. It is a very sobering and realistic stage. Now that the acute phase of illness has subsided, the nurse faces the realization that this person may not be able to work, may not know her, may not have his family visit, or may have limitations in living which are beyond aid. In most cases, however, he has assets that she can help to grow and develop.
She must also realize that the course of a long-term illness is not over in one hour, one day, one week, or one month, but that it may go on for years. She and the patient will have to work constantly to reestablish their own homeostasis or equilibrium. The patient will need encouragement, courage, and varying degrees of complete help on days he feels that he can be quite independent physically and emotionally. He may even support the nurse on other days and give her courage. On days when the patient needs her (very dependent physically or emotionally), she will support him. When a nurse and her patient have gone through experiences together, there develops a relationship in which the nurse and patient develop a mutually helpful symbiosis. Helping a person to the comfortably is a rewarding and awesome function. There are many ways in which a nurse can do this. She is never more eloquent And if her nursing has been positive, she may know that she has not failed but has succeeded grandly.
- Dunn, Halbert L.: "What High Level Wellness Means," National Office of Vital Statistics, United States Department of Health, Education, and Welfare, Public Health Service, Washington 25, D. C. Mimeographed, March 4, 1959.
- Knowles, Lois N.: "How Our Behavior Affects Patient Care," The Canadian Nurse, vol. 58, no. 1, pp. 30-33, 1962.
- Lansing, Albert L: Cowdry's Problems of Aging, The Williams andWilkins Company, Baltimore, 1952.
- Worcester, Alfred: The Care of the Ag ed, the Dying, and the Dead, Charles C. Thomas, Publisher. Springfield, Illinois, 1961.