الفهرس 
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Abstract
Orthostatic hypotension (OH) is a common disorder in the elderly population and increases with advancing age. It is defined asis a sustained fall of systolic blood pressure of 20 mm Hg or lowering diastolic blood pressure by 10 mm Hg within three minutes of standing that can cause symptoms of organ hypoperfusion. Orthostatic hypotension is associated with increased morbidity and mortality and leads to a significant number of hospital admissions, particularly in the elderly. In this context, it is important for the gerontological nurses to monitor and treat OH to reduce its symptoms severity, increase the standing time, improve the older adults ability to carry out everyday activities as well as improving quality their of life.
Aim of the study:
The present study aimed to determine the effect of nursing interventions on the severity of orthostatic hypotension among older adults residing in assisted living facilities.
Research hypothesis:
Older adults residing in assisted living facilities who receive the proposed nursing interventions achieve lower score on the orthostatic hypotension grading scale than before the interventions.
Research tools and method:
Design: This study followed a quasi-experimental research design.
Setting: The study was carried out in two settings: Dar-El Hedaya and Dar–EL Mouwasah. These two assisted living facilities are affiliated to the Ministry of Social Solidarity, Alexandria, Egypt.
Subjects: The subjects of this study comprised of a convenient sample of all available older adults residing in the above mentioned settings at the time of the study, and fulfilling the following criteria; aged sixty years and above,able to communicate effectively, with no or mild cognitive impairment according to theSaint Louis University Mental Status Examination ,with no or mild depression based on the geriatric depression scale short form, had orthostatic hypotension , able to assume a standing position alone, not on fluid restriction, and free from cellulitis, and chronic hypotension.
Based on subjects fulfilling these inclusion criteria: The number of older adults who were eligible for the study in the previously mentioned setting was forty older adults.
Tools of the study: five tools were used for data collection.
Tool (I): Saint Louis University Mental Status (SLUMS) Examination:
This tool was used to identify older adults with cognitive impairment.
Tool (II): Geriatric Depression Scale Short-Form (GDS-SF):
This GDS-SF was used to assess depression and general well-being in the older adults.
Tool (III): Orthostatic Vital Signs Measurement Scale.
This tool aimed to measure blood pressure, pulse rate and include questions related to symptoms for patients who were at risk for hypovolemia as the result of vomiting, diarrhea, and bleeding, or have had syncope or near syncope symptoms as dizziness and fainting, or were at risk for falls.
Tool (IV): Older Adults Socio–Demographic and Clinical Data Structured Interview Schedule.
This tool was developed by the researcher based on in-depth review of recent relevant literatures and consisted of two parts as follows:-
Part I: Socio-demographic data of the older adults which comprised of; Age, gender, marital status, level of education, occupation prior to retirement and monthly income.
Part II: Clinical data of the older adult’s medical health history including; the presence of any medical condition affecting OH, the presence of comorbid diseases or medications that may contribute to OH.
Tool (V): Orthostatic hypotension Grading Scale
The Orthostatic hypotension Grading Scale was used to assess the frequency and severity of orthostatic symptoms, relationship of symptoms to orthostatic stressors, and impact of symptoms on activities of daily living and standing time.
Research Methodology:
After the necessary approvals has been taken and the tools and nursing were interventions developed and prepared, the older adults were interviewed individually in the study setting to select the eligiblestudy subjects according to the inclusion criteria. The older adults were informed about the aim of the study and the session’s schedule. Prior to implementing the program; assessment of the study subjects’ socio-demographic and clinical data, orthostatic hypotension, the frequency and severity of orthostatic symptoms, the relationship of symptoms to orthostatic stressors, the impact of symptoms on activities of daily living and standing time, were performed.
The proposed nursing interventions were conducted in 5 sessions, over 3 weeks period (2 sessions per week). Each session took about 30-45 minutes.The five nursing interventions program sessions’ implementation was conducted as follows; in session (1); the researcher screen all older adults in the selected assisted living facilities; in order to determine their eligibility for participation in the study. Those who fulfilled the criteria and willing to participate in the study; were included. Session (2); the researcher explained the importance of the proposed nursing intervention sessions, the planned goals to be achieved. Then the researcher gave simple information about OH using flip chart. Session (3); the researcher implemented bolus of water intervention and evaluated its effect on the severity of OH and its associated symptoms. Session (4); researcher implemented standing cross legged intervention and evaluated its effect on the severity of OH and its associated symptoms. Session (5); the researcher implemented supine leg exercise intervention and evaluated its effect on the severity of OH and its associated symptoms.
Along with all sessions, the researcher reviewed each action plan calendar to assess the older adult’s commitment. The second evaluation was done after two weeks of implementing the last nursing intervention session by measuring the orthostatic hypotension, the frequency and severity of orthostatic symptoms, the relationship of symptoms to orthostatic stressors, the impact of those symptoms on activities of daily living, as well as the standing time. Data were collected from the beginning of February to the end of April 2021.The statistical package of social science ”SPSS” were used for data analysis and tabulation. The level of significance was ≤ 0.05.
Results obtained were as follows:
The age of the study older adults ranged from sixty to less than eighty five years. Regarding the older adults gender, the result revealed that; (52.5%) were males. In relation to marital status, nearly two third of the elders (65%) were widows and widowers, and (2.5%) were married. Concerning the educational level, the result shows that (25%) had basic education, (22.5%) were able to read and write, (20%) completed secondary education, (17.5%) had university education and above, while (15%) were illiterate.
Moreover; concerning the occupation of the study older adults before retirement, it was observed that; nearly half of them (45%) had a skilled, and (25%) had no work and this included the house wifes. As regards the length of the stay in the elderly home, nearly two third (65%) of the study older adults stayed for less than five years. While concerning the living conditions, an equal proportion of the study older adults (40%) lived either alone or with two or more persons in his ∕ her room.
As for years of having orthostatic hypotension, it was obvious that; the majority (95%) of the study subjects reported having orthostatic hypotension from one to less than three years. As regards orthostatic hypotension symptoms, it was obvious that; (100%) all the study older adults had lightheadness, nearly two third (65%) had visual changes, less than two third (62.5%) had dizziness, more than quarter (27.5%) had history of fall and fifth (20%) complained of fatigue.
Regarding seeking medical help for orthostatic hypotention, it was observed that; nearly three quarters (70%) of the study subjects didn’t seek any medical help for orthostatic hypotension, while the remaining (30%) sought medical help. Concerning the prescribed treatment for orthostatic hypotension, it was found that; the highest percentage of the study subjects(91.7%) reported that medical drugs was the prescribed treatment choice, one quarter (25%) reported that changing position gradually was their prescribed treatment, and the lowest percentage (8.3%) reported increase fluid intake was their prescribed treatment.
As regards the severity of orthostatic hypotension, it was found that; the mean scores of the standing systolic and diastolic blood pressure before and after two weeks of nursing interventions implementation were (110.50 ±24.59, 69.75 ±14.05)and (119.25 ±11.63, 77.25 ±7.506) respectively. While, the mean heart rate before and after two weeks was (75.70 ±6.136) and (80.40 ±6.071); respectively. As well, a highly statistically significant difference was observed between the orthostatic hypotention symptoms before and immediately after the nursing interventions implementation (P= 0.000).
Conclusion:
Based on the findings of the present study, it can be concluded that; Implementing the three nursing interventions namely”Bolus of water, Physical counter maneuvers, and Supine leg exercise ”over a period of two weeks resulted in a statistically significant increase in standing blood pressure (BP), and improvement of the orthostatic hypotention symptoms severity among older adults residing in the study assisted living facilities. Thus; the study hypothesis is supported by the study data.
Recommendations:
Based on the findings of the present study, the following recommendations are derived and suggested:
1. Nurses in the assisted living facilities should be educated by the staff of the gerontological nursing department about the importance of including the problem of OH, and its causes in the assessment of older adults.
2. In-service training program utilizing the developed educational booklets and posters has to be planned and implemented regularly by the faculty members of the gerontological nursing department and offered on regular basis for nurses and caregivers in the assisted living facilities about the importance of OH - age related changes, complication of OH as well as the importance of OH resident’s adherence to therapeutic regimens for complications prevention.
3. Multidisciplinary meetings with thegerontological nursing department faculty member andthe assisted living facilities nurses has to be conducted regularly for discussing OH in older adults, its consequences and the availability and importance of seeking medical help for assisted living facilities residences.
Recommendations for future researches:
1. Replication of the present study on a larger sample size.
2. The duration of the effect of nursing intervention on OH and it’s associated symptoms requires further investigation on a larger time period.
3. A comparative study can be conducted on the effectiveness of different nursing interventions on OH among older adults residing in assisted living facilities