Applying a Nursing Model for Promoting Wellness in Older Adults
chapter 3 Applying a Nursing Model for Promoting Wellness in Older Adults LEARNING OBJECTIVES After reading this chapter, you will be able to: Discuss the concepts that underpin the Functional Consequences Theory in older adults. Define concepts of age-related changes, risk factors, and functional consequences as they relate to nursing care of older adults. Describe the domains of nursing (i.e., person, nursing, health, environment) in the context of the Functional Consequences Theory. Apply the Functional Consequences Theory to the practice of nursing to promote wellness in older adults. KEY TERMS age-related changes environment functional consequences Functional Consequences Theory for Promoting Wellness in Older Adults health interprofessional collaboration negative functional consequences nursing older adult person positive functional consequences risk factors wellness wellness outcomes As discussed in Chapter 1, myths about aging are insidious and pervasive in society and form the foundation of ageism, which has serious detrimental effects on older adults. Nurses are influenced not only by societal myths and ageist attitudes but also by their experiences with older adults in health care settings, which often reinforce the perception that older adults are frail, confused, depressed, and dependent. These attitudes can lead to a sense of pessimism—or even hopelessness—regarding caring for older adults. Fortunately, knowledge can be an effective antidote to ageism, and the theoretical base of information about aging has expanded exponentially during the past half-century. Research-based information enables health care providers to differentiate between age-related changes that are inevitable and risk factors that can be addressed or even prevented. Chapters in this text provide research-based information about age-related changes and risk factors affecting a particular aspect of functioning, with emphasis on the changes and risks that nurses can address. Nurses can apply this information to promote wellness for older adults by identifying ways of improving functioning and quality of life. As discussed in Chapter 4, theories about aging and older adults attempt to answer questions about why and how people age, and they provide a base for identifying the risk factors that health care providers can address. However, they do not address nursing care of older adults, as does a nursing theory that explains relationships among the core concepts of person, nursing, health, and environment. Discipline-specific nursing theories guide nursing care and are essential to promoting wellness for older adults. The Functional Consequences Theory for Promoting Wellness in Older Adults, which is delineated in this chapter and used throughout this text, provides a framework that nurses can use to promote wellness and improve functioning and quality of life for older adults. A NURSING THEORY FOR WELLNESS-FOCUSED CARE OF OLDER ADULTS During the 1980s, this author proposed a model for gerontological nursing, which was the organizational framework for the first edition of this book (Miller, 1990). Since its inception, this model has emphasized the significant role of nurses in using health education interventions to promote optimal health, functioning, and quality of life for older adults. In the fifth and sixth editions, some terminology was revised to reflect current emphasis on adding life to years in conjunction with adding years to life. Thus, the model is now called the Functional Consequences Theory for Promoting Wellness in Older Adults. In addition, the updated model reflects and incorporates the evolving understanding of wellness as an integral aspect of health care. Nurses are among the health care professionals who have increasingly emphasized the need to incorporate wellness-oriented goals into their care plans. The Functional Consequences Theory can be used to achieve these goals in all aspects of nursing care for older adults because it addresses essential questions, such as “What is unique about promoting wellness for older adults?” and “How can nurses address the unique wellness needs of older adults?” The purpose of nursing theories is to describe, explain, predict, or prescribe nursing care based on scientific evidence. Since the time of Florence Nightingale, nurses have developed theories that address the relationships among the domains of person, nursing, health, and environment. The Functional Consequences Theory is based on a combination of research on aging and health and the author’s more than four decades of providing nursing care for older adults. It also draws on theories that emphasize concepts related to wellness, health promotion, and holistic nursing. In this text, up-to-date and evidence-based information about specific aspects of functioning is applied to nursing care of older adults in the framework of the Functional Consequences Theory. Basic premises of the Functional Consequences Theory are as follows: Holistic nursing care addresses the body–mind–spirit interconnectedness of each older adult and recognizes that wellness encompasses more than physiologic functioning. Although age-related changes are inevitable, many risk factors can be prevented or alleviated. Older adults experience positive or negative functional consequences because of a combination of age-related changes and risk factors. Interventions can be directed toward alleviating or modifying the negative functional consequences of risk factors. Nurses can promote wellness in older adults through health promotion interventions and other nursing actions that address the negative functional consequences. Nursing interventions result in positive functional consequences, also called wellness outcomes, which enable older people to function at their highest level despite the presence of age-related changes and risk factors. This theoretical framework, shown in Figure 3-1, can be illustrated by the following example. Because of age-related visual changes, older adults experience an increased sensitivity to glare and have difficulty seeing clearly when they face bright lights or when lights reflect off shiny surfaces. For instance, older adults may have difficulty seeing clearly when they are driving toward the sunlight or reading shopping mall maps in glass cases. In addition to this age-related change, older adults are likely to have disease-related conditions, such as cataracts, that further interfere with their visual abilities. In addition, environmental factors, such as bright lights, highly polished floors, and white or glossy paint, can intensify glare. These age-related changes and risk factors can interfere with vision to the extent that older adults stop performing activities or perform them unsafely. To counteract these functional consequences, the older person or a nurse can initiate any of the following interventions, which are discussed in Chapter 17: Wearing sunglasses and using glare-reducing glasses (self-care) Addressing environmental conditions by using adequate nonglare lighting (self-care) Obtaining periodic evaluations from an ophthalmologist (self-care) Teaching about the use of sunglasses and glare-reducing glasses (nursing action) Teaching about and facilitating environmental modifications (nursing action) Taking actions to avoid glare (e.g., not standing in front of a bright window when talking with an older adult) (nursing action) Teaching older adults about the importance of having their eyes evaluated at least annually for treatable conditions (nursing action) Wellness outcomes resulting from these interventions include improved safety, function, and quality of life. CONCEPTS UNDERLYING THE FUNCTIONAL CONSEQUENCES THEORY The Functional Consequences Theory draws from theories that are pertinent to aging, older adults, and holistic nursing. The nursing domain concepts of person, environment, health, and nursing are linked together specifically in relation to older adults. Before discussing these domain concepts, however, the concepts of functional consequences, age-related changes, and risk factors are explained. Box 3-1 summarizes the key concepts in the Functional Consequences Theory for Promoting Wellness in Older Adults. Functional Consequences Functional consequences are the observable effects of actions, risk factors, and age-related changes that influence the quality of life or day-to-day activities of older adults. Actions include, but are not limited to, purposeful interventions initiated by either older adults (i.e., self-care) or nurses (i.e., nursing interventions) and other caregivers. Risk factors can originate in the environment or arise from physiologic and psychosocial influences. Functional consequences are negative when they interfere with a person’s level of function or quality of life or increase a person’s dependency. Conversely, they are positive when they facilitate the highest level of performance and the least amount of dependency. image FIGURE 3-1 The Functional Consequences Theory for Promoting Wellness in Older Adults. Age-related changes and risk factors combine to cause negative functional consequences. Nurses holistically assess older adults and initiate interventions to counteract or minimize negative functional consequences. Nursing actions result in wellness outcomes. Negative functional consequences typically occur because of a combination of age-related changes and risk factors, as illustrated in the example of impaired visual performance. They also may be caused by interventions, in which case the interventions become risk factors. For example, constipation resulting from the use of an analgesic medication is an example of a negative functional consequence caused by an intervention. In this case, the medication is both an intervention for pain and a risk factor for impaired bowel function. Box 3-1 Concepts in the Functional Consequences Theory for Promoting Wellness in Older Adults Functional Consequences: Observable effects of actions, risk factors, and age-related changes that influence the quality of life or day-to-day activities of older adults. The effects relate to all levels of functioning, including body, mind, and spirit. Negative functional consequences: Those that interfere with the older adult’s functioning or quality of life. Positive functional consequences: Those that facilitate the highest level of functioning, the least dependency, and the best quality of life. When positive functional consequences are the result of nursing interventions, they are called wellness outcomes. Age-Related Changes: Inevitable, progressive, and irreversible changes that occur during later adulthood and are independent of extrinsic or pathologic conditions. On the physiologic level, these changes are typically degenerative; however, on psychological and spiritual levels, they include potential for growth. Risk Factors: Conditions that increase the vulnerability of older adults to negative functional consequences. Common sources of risk factors include diseases, environment, lifestyle, support systems, psychosocial circumstances, adverse medication effects, and attitudes based on lack of knowledge. Older Adult (Person): A complex and unique individual whose functioning and well-being are influenced by the acquisition of age-related changes and risk factors. When risk factors cause the older adult to be dependent on others for daily needs, their caregivers are considered an integral focus of nursing care. Nursing: The focus of nursing care is to minimize the negative effects of age-related changes and risk factors and to promote wellness outcomes. Goals are achieved through the nursing process, with particular emphasis on health promotion and other nursing interventions that address the negative functional consequences. Health: The ability of older adults to function at their highest capacity, despite the presence of age-related changes and risk factors. It is not limited to physiologic function and encompasses psychosocial and spiritual function. Thus, it addresses well-being and quality of life as defined by each older adult. Environment: External conditions, including caregivers, that influence the body, mind, spirit, and functioning of older adults. Environmental conditions are risk factors when they interfere with function, and they are interventions when they enhance function. Positive functional consequences can result from automatic actions or purposeful interventions. Often, older adults bring about positive functional consequences when they compensate for age-related changes with or without conscious intent. For example, an older person might increase the amount of light for reading or begin using sunglasses without realizing that these actions are compensating for age-related changes. At other times, older adults initiate interventions in response to a recognized need. In the example cited earlier, improved function would likely result from purposeful interventions, such as cataract surgery or environmental modifications. In a few instances, positive functional consequences are caused directly by age-related changes. For example, a woman may view the postmenopausal inability to become pregnant as a positive effect of aging. Consequently, sexual relationships may become more satisfying in later adulthood. Similarly, positive functional consequences, such as increased wisdom and maturity, can result from psychological growth in older adulthood. In the context of the nursing process, positive functional consequences are called wellness outcomes because they result from purposeful nursing interventions. The concept of functional consequences draws on concepts and research regarding functional assessment, which focuses on a person’s ability to perform activities of daily living that affect survival, overall health, and quality of life, as discussed in Chapter 7. From a research perspective, functional assessment provides a framework for research and a method for planning health services for dependent people. From a clinical perspective, health care practitioners view the multidimensional functional assessment as an important component in the care of older people. Evidence-based tools are widely available for assessing specific aspects of functioning and activities of daily living, and there is strong support for using these tools in clinical settings. Although the Functional Consequences Theory draws on concepts related to functional assessment, its scope is much broader. The Functional Consequences Theory differs from functional assessment in the following ways: It distinguishes between age-related changes that increase a person’s vulnerability and risk factors that affect function and quality of life. It focuses on functional consequences that can be addressed through nursing interventions. It focuses on assessment of conditions that affect functioning, rather than on identification of a person’s functional level. It leads to interventions that address negative functional consequences. It leads to wellness outcomes, such as improved functioning and quality of life. Many standardized and easy-to-use assessment tools are available for use in clinical settings, and those that are most pertinent to nursing care of older adults are cited in clinically oriented chapters of this text. In addition, all clinically oriented chapters contain comprehensive assessment and intervention boxes that apply evidence-based information to a wellness-oriented approach to nursing care of older adults (see list in the front of this book). Age-Related Changes and Risk Factors A unique challenge of caring for older adults is the need to differentiate between age-related changes and risk factors, because the interventions for age-related changes differ from those for risk factors. Age-related changes cannot be reversed or altered, but it is possible to compensate for their effects so that wellness outcomes are achieved. By contrast, risk factors can be modified or eliminated to improve functioning and quality of life for older adults. In the Functional Consequences Theory, age-related changes are the inherent physiologic processes that increase the vulnerability of older people to the detrimental effects of risk factors. From a body–mind–spirit perspective, however, age-related changes are not limited to physiologic aspects but include potential for increased cognitive, emotional, and spiritual development. Thus, nurses holistically focus on the whole person by identifying age-related changes that can be strengthened to improve the older adult’s ability to adapt to physiologic decline. For example, nurses can work with older adults to strengthen their coping skills, as discussed in Chapter 12. In addition, nurses have many opportunities to build on the wisdom of older adults, especially their “everyday problem-solving” skills (as discussed in Chapter 11), by teaching about interventions to address risk factors. The definition of age-related changes in the context of the Functional Consequences Theory draws primarily on research on aging. Biologic theories can help differentiate between age-related and disease-related processes; usually, however, there is some overlap among these processes as discussed in Chapter 4. In addition to biologic theories of aging, other theories about aging and older adulthood can shed light on age-related changes that contribute to the ability of older adults to respond to the challenges of aging. Clinically oriented chapters in this text discuss research on age-related changes pertinent to specific aspects of functioning. A Student’s Perspective Most older adults live outside nursing homes and are actively involved in maintaining their independence and functional abilities as much as possible. Having worked in an acute care setting for many years, it is very easy for me to assume that all older adults have many underlying chronic diseases and do very little to comply with their medical therapies. It does help to separate what is a part of the aging process from what is part of a chronic condition, since problems resulting from chronic conditions may be receptive to medical and nursing interventions. Darris C. Risk factors are the conditions that are likely to occur in older adults and have a significant detrimental effect on their health and functioning. Risk factors commonly arise from environments, acute and chronic conditions, psychosocial conditions, or adverse medication effects. Although many risk factors also occur in younger adults, they are more likely to have serious functional consequences in older adults because of the following characteristics: They are cumulative and progressive (e.g., long-term effects of smoking, obesity, inadequate exercise, or poor dietary habits). The effects are exacerbated by age-related changes (e.g., effects of arthritis are exacerbated by diminished muscle strength). The effects may be mistakenly viewed as age-related changes rather than reversible and treatable conditions (e.g., cognitive changes from adverse medication effects may be attributed to normal aging or dementia). They would not have negative functional consequences in a younger person (e.g., glare or background noise would not affect the vision or hearing of someone who is not experiencing age-related sensory changes). Researchers and health care providers commonly address risk factors in relation to prevention and treatment of medical conditions. For example, evidence-based practice guidelines for pharmacologic or surgical treatments often weigh the probable risks versus benefits. Similarly, researchers focus on identifying risk factors for developing conditions, such as heart disease, so these risks can be addressed through health promotion interventions. Nurses incorporate the concept of risk factors in many aspects of the nursing process. For example, many nursing diagnoses, interventions, and outcomes address risk control, risk identification, or risk detection. In the context of nursing diagnosis, NANDA-International states that “sometimes a risk diagnosis can be the diagnosis with the highest priority for a patient” (Gallagher-Lepak, 2018, p. 38). A major focus of wellness-focused nursing is to identify risk factors that can be addressed through health promotion interventions. For example, from a health promotion perspective, nurses routinely assess for risks associated with stress, smoking, obesity, poor nutrition, and inadequate physical activity. An aspect that is unique to caring for older adults is the need to identify myths or ageist attitudes that can affect health care. For example, if urinary incontinence is mistakenly attributed to “normal” aging, then the older adult will not receive appropriate evaluation and interventions. Environmental risks are also particularly pertinent to older adults because additional risk factors, such as sensory, mobility, or cognitive impairments, can compromise their safety and functioning. Identification of risk factors is an integral aspect of the Functional Consequences Theory because nurses have numerous opportunities for promoting wellness by identifying and addressing the many modifiable factors that affect functioning and quality of life for older adults. Person In the Functional Consequences Theory, the concept of person applies specifically to older adults. Because the holistic approach of the theory views each older adult as a complex and unique individual whose functioning and well-being are influenced by many internal and external factors, older adults are not defined simply according to chronologic criteria. From this perspective, an older adult is characterized by the acquisition of physiologic and psychosocial characteristics that are associated with increasing maturity. Physiologic characteristics include slowing down of physiologic processes, compromised ability to respond to physiologic stress, and increased vulnerability to pathologic conditions and other risk factors. Psychosocial characteristics include an increased potential for psychosocial strengths, such as wisdom and creativity, and the potential for advanced levels of personal and spiritual growth. Because aging is a complex and gradual process involving all aspects of body, mind, and spirit, a person does not suddenly become an older adult at a particular chronologic age. Rather, people who live long enough recognize at some point that they have reached a stage of life that society categorizes as older adulthood. When they reach this point, they may or may not identify with social labels, such as elder, senior, or older adult. Although this conceptual approach has the distinct disadvantage of being difficult to measure, it has the advantage of accurately reflecting the realities of older adulthood as one part of the life-course continuum. Because people become more heterogeneous rather than homogeneous as they age, any definition of the older adult must, by its nature, be broad. In the context of the Functional Consequences Theory, an individual is an older adult when he or she manifests several or many functional consequences attributable to age-related changes alone or to age-related changes in combination with risk factors. Stated simply, it is the accumulation of age-related functional consequences that is the core criterion for defining someone as an older adult. Moreover, because aging involves many gradual, interacting, and cumulative processes, each older adult experiences his or her own unique continuum. This concept is applied in the unfolding case examples in chapters of Parts 3 and 4 of this book, with each case illustrating the progression of an individual from young–old to old–old as he or she is affected by functional consequences pertinent to a particular aspect of functioning. These unfolding case examples illustrate roles of nurses in promoting wellness for an older adult as he or she experiences several phases of health and illness during the course of older adulthood. The older adult is further conceptualized in the context of his or her relationships with others because a person is not an isolated entity but a dynamic being who continually influences and is influenced by the environment and other people. This context is particularly important for older adults, because the more functionally impaired a person is, the more important are support resources and environmental factors. When functional consequences accumulate to the extent that the older adult depends on others for daily needs, nurses broaden their focus to include caregivers during nursing assessments and interventions. In all circumstances, it is important to address the needs of older adults in the context of their relationships because older people have a long history of interpersonal relationships that influence their health behaviors and well-being. Although no characteristics are universally applicable to all older adults, all are affected by the cumulative effects of aging and all are vulnerable to the effects of risk factors. Thus, it is imperative to be knowledgeable about normal aging so nursing care can address negative functional consequences. The Functional Consequences Theory emphasizes the importance of identifying and respecting the unique characteristics of each older adult that affect his or her functioning and well-being. Nursing The conceptualization of nursing in the Functional Consequences Theory draws on nursing theories, including those of long-established theorists, as described in Box 3-2. An additional aspect of the Functional Consequences Theory is its emphasis on person-centered care, which focuses on older adults as the center of their own care. The individualized needs of older adults are addressed and there is a sharing of power and responsibility. Nurses involve older adults in decision making because they recognize that older adults are experts in their own health. In addition, the person-centered approach includes families and caregivers as appropriate in all aspects of assessment, planning, and interventions. The approach used throughout this text is consistent with current emphasis on person-centered, family-centered, and culture-centered health care, based on a comprehensive assessment of individual needs and preferences. Content for all clinically oriented chapters is presented in the framework of the nursing process and applied to a particular aspect of functioning. The first figure in most chapters illustrates how nurses can apply the Functional Consequences Theory to their nursing care of older adults in relation to a specific aspect of functioning. Health and Wellness The Functional Consequences Theory defines health as the ability of older adults to function at their highest capacity, Health and Wellness The Functional Consequences Theory defines health as the ability of older adults to function at their highest capacity, despite the presence of age-related changes and risk factors. It encompasses psychosocial as well as physiologic function, including well-being and quality of life as defined by each older adult. In this model, health is individually determined, based on the functional capacities that are perceived as important by that person. For example, one person might define the desired level of function as a capacity for intimate relationships, whereas another might define it as being able to perform aerobic exercise for half an hour daily. Definitions of health by major nursing theorists that are consistent with the conceptualization of health in the Functional Consequences Theory are summarized in Box 3-3. Box 3-2 Nursing Theories That Support the Conceptualization of Nursing in the Functional Consequences Theory Florence Nightingale: Nurses foster an environment conducive to healing and health promotion. Virginia Henderson: Nurses provide assistance with daily activities to help patients/clients gain independence as rapidly as possible. Imogene King: Nurse and client interact to achieve a specific health-related goal. Jean Watson: Nursing consists of knowledge, thought, values, philosophy, commitment, and action with passion in human care transactions. Martha Rogers: Nurses promote person–environment interactions for unitary human beings. Margaret Newman: Nursing is the act of assisting people to use their power to evolve toward higher levels of consciousness. Wellness is a closely related concept that is used throughout this book in reference to the person’s highest potential for well-being. A concept analysis of wellness in older adults described it as “a purposeful process of individual growth, integration of experience, and meaningful connection with others, reflecting personally valued goals and strengths, and resulting in being well and living values” (McMahon & Fleury, 2012, p. 48). Similarly, in the context of current emphasis on person-centered care, wellness is conceptualized as “the meaning a person brings to his/her life experience, and yes, that life experience may include living with and managing disease” (Fulton, 2016, p. 136). These concepts are consistent with the Functional Consequences Theory as it is applied to the nursing care of older adults. Environment In the Functional Consequences Theory, environment is a broad concept that includes all aspects of the setting in which the care is provided; for dependent older adults, the environment also includes their caregivers. Some aspects of the conceptualization may seem to be contradictory because the environment can be a source of both negative functional consequences and wellness outcomes. For example, the environment is a risk factor when it interferes with functioning (e.g., glare or poor lighting), but it also can facilitate wellness outcomes when it is used to improve functioning (e.g., grab bars, or bright and nonglare lighting). Box 3-4 summarizes some nursing conceptualizations of the environment that are pertinent to the Functional Consequences Theory. Box 3-3 Definitions of Health That Support the Conceptualization of Health in the Functional Consequences Theory Florence Nightingale: to be well, but to be able to use well every power we have Imogene King: a dynamic life experience involving continuous adjustment to stressors through optimum use of one’s resources to achieve maximum potential for daily living Callista Roy: a state and process of being and becoming integrated and whole Jean Watson: unity and harmony within the mind, body, and soul; congruence between the self as perceived and the self as experienced Margaret Newman: expanding consciousness; evolving pattern of the whole of life Rosemarie Parse: a way of being in the world; the living of day-to-day ways of being Madeleine Leininger: a state of well-being that is culturally constituted, defined, valued, and practiced by individuals or groups that enables them to function in their daily lives Nola Pender: the actualization of inherent and acquired human potential through goal-directed behavior, competent self-care, and satisfying relationships with others Box 3-4 Definitions of Environment From Nursing Theories That Are Pertinent to the Functional Consequences Theory Florence Nightingale: A healthy environment is essential for healing and includes specific aspects such as noise level, cleanliness, and nutritious food Madeleine Leininger: The totality of an event, situation, or particular experience that gives meaning to human expressions, interpretations, and social interactions in particular physical, ecologic, sociopolitical, and cultural settings Imogene King: The background for human interactions, which is both internal and external to the individual Margaret Newman: All internal and external factors of influences that surround the client or system Callista Roy: All conditions, circumstances, and influences that surround and affect the development and behavior of humans Since the 1970s, gerontologists have studied the influence of the environment on functioning of older adults. For example, the Person–Environment Fit Theory (discussed in Chapter 4) focuses on the interrelationship between the individual person and his or her environment. This theory has been used in studies of the effects of physical and social environments on many aspects of functioning and quality of life for older adults. Current emphasis is on the need to develop age-friendly environments in communities as well as supportive environments for older adults in long-term care settings (Davis & Weisbeck, 2016; Menec, Newall, & Nowicki, 2016; Rodiek, Nejati, Bardenhagen, et al., 2016). Some of the questions that gerontologists as well as nurses address include the following: How does the environment affect the older adult’s level of functioning? How does the environment affect the older adult’s quality of life? Is the environment comfortable for the older adult? Is the environment a source of risks that interfere with functioning and well-being of the older adults, for example, does it increase the risk for falls? How can the environment be adapted to improve functioning for the older adult? Throughout this text, the Functional Consequences Theory provides a framework for addressing questions such as these as an integral part of the nursing assessment and interventions for specific aspects of functioning. In addition to focusing on the environment as it affects older adults individually, this text focuses on broader aspects of the older adult’s environment, such as social supports, interpersonal relationships, and emotional and spiritual factors. Also, in keeping with current emphasis on the effects of health care environments, this text addresses the practice environments in which nurses care for older adults, including institutional, home, and community settings. This is consistent with the increasing recognition that interprofessional collaboration is an essential component of all health care environments. Nurses have crucial leadership roles in assuring that care for older adults is provided in an environment that is based on interprofessional collaboration. This topic is discussed in more detail in Chapter 6, and throughout this text content related to this topic is designated by the icon or with an IPC bar to the right of the text (as shown here). Online Learning Activity 3-1 provides a link to an article describing environments of care in relation to the nursing theories and the practice of nursing. See ONLINE LEARNING ACTIVITY 3-1: ARTICLE, A PRACTICE THEORY APPROACH TO UNDERSTANDING THE INTERDEPENDENCY OF NURSING PRACTICE AND THE ENVIRONMENT at http://thepoint.lww.com/Miller8e. Interprofessional Collaboration Characteristics of environments of interprofessional collaboration are: (a) the patient and family are always at the center of care, (b) health care team members communicate effectively, and (c) a shared decision-making approach encourages the full contribution of all involved (Talley, 2016). APPLYING THE THEORY TO PROMOTE WELLNESS IN OLDER ADULTS In the context of the Functional Consequences Theory, nurses direct their care toward addressing risk factors and promoting wellness outcomes for older adults. The focus and goals of this type of care vary in different settings. For acute care, the focus is on treatment of pathologic conditions that create serious risks; goals include helping vulnerable older adults recover from illness and maintain or improve their level of functioning. For long-term care, the focus is on addressing multiple risk factors that interfere with functional abilities; goals include improved functioning and quality of life. The Functional Consequences Theory is particularly pertinent in rehabilitation settings, where the focus is on preventing negative functional consequences and promoting wellness outcomes (Gouveia, Jardim, & Martins, 2011). For home and community settings, the focus is on short- and long-term interventions aimed at age-related changes and risk factors; goals include improving or preventing declines in functioning and addressing quality-of-life concerns. In all settings, nurses can incorporate wellness outcomes to address each older adult’s personal aspirations toward well-being of body, mind, and spirit. Examples of these wellness outcomes are delineated in all clinically oriented chapters of this text. A Student’s Perspective Today I cared for L.C., who has had two previous cerebrovascular accidents, with the second one leading to left-sided hemiplegia. As I was caring for her, I noticed a few things in her room that may have significance for her. First, I noted that she had poles both by her bed and in the bathroom; both were bolted to the ceiling and the floor. These poles made it easier for L.C. to stand on her own with little assistance from anyone else. I feel that these make her more independent and help her use the strong side of her body. L.C. also had a divided box, with different kinds of tea in each section. I feel that this is significant to her because she is able to have the type of tea she likes whenever she wants it. It allows her to make choices each day and provides one of the comforts of “home.” A third item was a triangle pillow that she sleeps on rather than a regular one. This is significant because it allows her to breathe better in the night or whenever she is sleeping. Because L.C. has chronic obstructive pulmonary disease, it is hard for her to breathe. Kelly Z. Nurses apply the nursing process to assess age-related changes and risk factors, identify nursing diagnoses, plan wellness outcomes, implement nursing interventions to achieve wellness outcomes, and evaluate the effectiveness of their interventions. A major focus of nursing care is on educating older adults and caregivers of dependent older adults about interventions that will eliminate risk factors or minimize their effects. The educational aspects are particularly important when older adults are influenced by myths and misunderstandings about age-related changes. For example, nurses can provide information about the difference between normal aging changes and risk factors to an older person who believes that functional impairments are a necessary consequence of old age and identify ways of minimizing the effects of risk factors and compensating for the effects of age-related changes. Providing nursing care for older adults can be both challenging and rewarding, despite the common perception that it is futile and discouraging. Although nursing care of older adults is often associated with limited goals, a holistic perspective focuses on the potential of every person to experience wellness by achieving higher levels of psychological or spiritual functioning. Even older adults who have dementia, and other progressive conditions that can profoundly affect functioning and quality of life, may have potential for spiritual growth in ways that are not always observable or measurable. The Functional Consequences Theory helps nurses see older adults as more than an accumulation of age-related physiologic changes and pathologic conditions leading to diminished functioning. Thus, it provides a framework for promoting wellness because it addresses the whole-person needs of the older adult and his or her relationships with self, others, and the environment. It reminds nurses to identify strengths and potentials in relation not only to physical aspects of functioning but also to psychological and spiritual well-being. Moreover, it leads to nursing interventions directed toward achieving wellness outcomes, such as improved quality of life for older adults.