Nursing

Geriatric Essentials

• Nurses can improve patient outcomes by facilitating early interventions for problems common among the elderly, particularly skin breakdown, dehydration, undernutrition, delirium, and falls.
• Another important function of nurses is teaching elderly patients and their family members about health care and treatment.
• Nurses may obtain specialty certification as a generalist, a clinical specialist, or a nurse practitioner in gerontology through the American Nurses Credentialing Center.
• Geropsychiatric advanced practice nurses specialize in geriatric psychiatric care.

In the US, there are several educational and licensing levels for nurses, including practical nurses, registered nurses, and registered nurses with added certifications. All nurses provide professional nursing care in settings ranging from a patient's home to ICUs.

Registered nurses supervise patients closely, round-the-clock in many settings, and thus are key members of interdisciplinary teams. Because they are more available than physicians, registered nurses can respond quickly to changes in a patient's health status and thus facilitate early interventions, preventing health from worsening unnecessarily. They plan and provide a wide range of geriatric care, including prevention of problems common among the elderly (eg, skin breakdown, incontinence, eating and feeding problems, dehydration, undernutrition, falls, confusion, delirium, sleep disorders, discomfort, pain). Nurses also recognize early signs of these problems if they occur and take steps to correct them.

Nurses regularly demonstrate self-care procedures (eg, how to irrigate a new colostomy, inject insulin, or care for pressure ulcers) and then observe the patient performing the procedures. Nurses regularly evaluate and document an elderly patient's ability to learn new information or behavior. Nurses also help evaluate the support available to the patient.

Nurses are essential to optimal teaching about health care and treatment, which can improve patient outcomes. In most settings, nurses explain tests and diagnostic and surgical procedures to the patient and family members. Nurses describe the environment in which surgery will occur and explain what patients may expect before, during, and after surgery. Nurses identify which patients learn best from written or printed information and which prefer videotaped information; they then tell the interdisciplinary team which teaching method a patient prefers.

Nurses can help patients better understand what a physician tells them. For example, after a gastroenterologist explains an endoscopy, a nurse, who is often more familiar with a patient's learning capabilities, can reinforce and expand the explanation, using simpler language and diagrams if necessary, and thus make sure the patient understands the procedure and related details. Nurses can discuss details that the patient did not discuss with the physician because the patient forgot, was embarrassed to discuss, or thought too mundane (eg, how long to wait before eating after an endoscopy, how to take an enema). Nurses may also prepare pamphlets containing pertinent information and phone numbers for patients.

Usually, nurses communicate with family members of hospitalized patients. On-going, open communication lets family members know that their input is valuable. Nurses are likely to obtain useful, accurate information about a patient's home life. Just before discharge, a nurse typically reviews treatment plans and follow-up appointments with the patient and the family members who will be involved in caregiving. Ideally, after the patient is discharged, a nurse is available to the patient and family members to reinforce what the patient has been taught (eg, self-care procedures) and to discuss new issues. Nurses are also responsible for communicating information to other nurses when patients are transferred to or from a nursing home, home care service, or other care setting.

Some nurses obtain specialty certification in gerontology as a generalist, a clinical specialist, or a nurse practitioner through the American Nurses Credentialing Center. They must pass a certification examination and fulfill other specific requirements for their area of practice.

Gerontologic Nurse Practitioners

Gerontologic (geriatric) nurse practitioners are registered nurses with a master's degree from a nurse practitioner program that focuses on care of the elderly. In 2004, only about 4,000 of > 100,000 certified nurse practitioners were certified gerontologic nurse practitioners. However, many certified family nurse practitioners and adult nurse practitioners also provide care for the elderly. The curriculum for gerontologic nurse practitioners focuses on normal aging, common problems of old age and their management, and detection of complex problems that typically require referral.

Gerontologic nurse practitioners perform many functions previously performed only by physicians. They perform physical examinations, diagnose disorders, order laboratory and other diagnostic tests, develop and implement treatment plans for patients with certain acute or chronic disorders, prescribe certain drugs, teach and counsel patients, provide long-term monitoring, consult with other health care practitioners, and refer patients to specialists. Nurse practitioners may practice in collaboration with physicians or other health care practitioners. As of 2005, nurse practitioners can be licensed as independent providers and can receive direct reimbursement from Medicare and Medicaid in about 14 states and the District of Columbia. The practice parameters for gerontologic nurse practitioners are defined by each state. See also the National Conference of Gerontological Nurse Practitioners' position statement Clinical Practice of Gerontological Nurse Practitioners.

Many gerontologic nurse practitioners work in nursing homes or for physicians with practices in nursing homes. Others work in acute care settings or in primary care offices. Community health services (eg, home care agencies, hospices, clinics) may be managed primarily by gerontologic nurse practitioners. Nursing roles have expanded because basic health care services are lacking in certain areas, especially rural areas and inner cities, and because few physicians make home visits. Many gerontologic nurse practitioners provide primary care in the community.

Clinical Specialists in Gerontologic Nursing

Clinical specialists in gerontologic nursing (often referred to as gerontologic or geriatric clinical nurse specialists) are registered nurses who have a master's or higher degree in nursing and who specialize in care of the elderly. Gerontologic clinical nurse specialists have substantial clinical experience with patients and their family members; they have expertise in formulating health and social policies and in planning, implementing, and evaluating health problems. They can also take histories, perform physical examinations, and manage medical and nursing problems. Unlike nurse practitioners, clinical nurse specialists usually cannot diagnose and cannot prescribe drugs.

Most gerontologic clinical nurse specialists work in hospitals as consultants to interdisciplinary teams. They consult for and advise staff nurses about problems common among the elderly and provide continuing education about new research findings. Gerontologic clinical nurse specialists also help staff nurses by serving as liaisons between the hospital and nursing homes or community health agencies. They may make home visits after a patient is discharged from the hospital and manage and coordinate care as a patient moves between several care settings.

Gerontologic clinical nurse specialists sometimes teach and train staff nurses more formally, as in the geriatric resource nurse program, which includes participation in interdisciplinary geriatric care rounds. After completing this training program, staff nurses are recognized as geriatric resource nurses, although no certification occurs. In addition to providing expert care for elderly patients, geriatric resource nurses provide information and support for other staff members caring for elderly patients and for patients and their family members. Geriatric resource nurses also act as advocates for elderly patients.

Geropsychiatric Advanced Practice Nurses

Geropsychiatric advanced practice nurses are clinical nurse specialists or nurse practitioners who have received additional training in geropsychiatry and mental health. The number of practicing geropsychiatric clinical nurse specialists and geropsychiatric nurse practitioners is unknown, partly because no certification procedure exists for geropsychiatry specialization. Geropsychiatric advanced practice nurses often work in hospitals, mental health clinics, and outpatient settings providing care for elderly patients with mental health impairments, especially those with cognitive impairment. Geropsychiatric advanced practice nurses perform physical examinations and psychiatric assessments of elderly patients and work with an interdisciplinary team concerned with the needs, particularly mental health needs, of the elderly. Geropsychiatric advanced practice nurses are also involved in discharge planning in collaboration with community agencies.

This topic was last updated June 2006.