CH 7: Geriartric Considerations

The nurse is caring for an older adult patient who is receiving multiple medications. When monitoring this patient for potential drug toxicity, the nurse should review which lab values particularly closely given the patients advanced age?

a. Complete blood count and serum glucose levels

b. Pancreatic enzymes and urinalysis

c. Serum creatinine and liver function tests (LFTs)

d. Serum lipids and electrolytes

ANS: C
With liver and kidney dysfunction, drug levels are generally increased and may cause toxicity due to decreased drug clearance. The nurse should review serum creatinine levels to monitor renal function and LFTs to monitor hepatic function. The other lab tests may be ordered for specific drugs if they affect those body systems.

An older patient who reports a 2- to 3-year history of upper gastrointestinal (GI) symptoms will begin taking ranitidine (Zantac) to manage her symptoms. The patient has completed a health history form. The nurse notes that the patient answered “no” when asked if any medications were being taken. Which action will the nurse take next?

a. Ask whether the patient uses any over-the-counter (OTC) medications.

b. Obtain a careful dietary history for the past two weeks.

c. Recommend that the patient take antacid tablets.

d. Suggest that the patient add high-potassium foods to her the diet

ANS: A

Many patients do not think of OTC products as medications and often do not list them when asked about medication use. A patient who takes ranitidine along with an OTC acid-lowering product could be duplicating therapy. A dietary history is important as well but would not be the most important action at this time. The nurse should not recommend antacid tablets or high- potassium foods before gathering additional information.

To assist an older, confused patient to adhere to a multidrug regimen, the nurse will provide which recommendation?

a. Avoid the use of OTC medications.

b. Bring all medications to each clinic visit.

c. Review the manufacturer’s information insert about each medication.

d. Save money by getting each drug at the pharmacy with the lowest price.

ANS: B
Patients who take multiple medications should be advised to bring medications to each clinic visit. Patients may take OTC medications as long as those are included in the list of medications reviewed by the provider. Manufacturers’ inserts provide an overwhelming amount of information. Patients should be encouraged to use only one pharmacy whenever possible.

*The nurse is caring for an older patient who is taking 25 mg per day of hydrochlorothiazide. The nurse will closely monitor which lab value in this patient?

a. Coagulation studies

b. White blood count

c. LFTs

d. Serum potassium

ANS: D
Older patients who take doses of hydrochlorothiazide between 25 and 50 mg/day have increased risk of electrolyte imbalances, so potassium should be monitored.

The nurse is caring for an 82-year-old patient who takes multiple prescription and over-the- counter medications. When caring for this patient, which of the following would NOT be considered a potential barrier to effective drug use that should be considered in this patient?

a. Impaired memory

b. Lower risk of side effects to indicate drug toxicity

c. Decreased mobility and dexterity

d. Visual disturbance

ANS: B
Older adults are not at lower risk for side effects, and actually can be at higher risk due to the number of medications they take. Impaired memory, decreased mobility and dexterity, and visual disturbances are all potential barriers to effective medication taking in older adults that should be considered in their care.

The nurse is caring for an 80-year-old patient who is taking warfarin (Coumadin). Which action does the nurse understand is important when caring for this patient?

a. Encouraging the patient to rise slowly from a sitting position

b. Initiating a fall-risk protocol

c. Maintaining strict intake and output measures

d. Monitoring blood pressure frequently

ANS: B
Patients who take anticoagulants have an increased risk of hemorrhage. Older patients have an increased risk of falls that can lead to bleeding complications. Initiating a fall-risk protocol is important. Warfarin does not affect blood pressure and would not cause orthostatic hypotension. Warfarin does not alter urine output.

An 80-year-old patient with chronic kidney disease (CKD) is being treated for an infection. The nurse knows that dose adjustment is not required for which of the following antibiotics based on the patient’s kidney disease?
a. Azithromycin
b. Nitrofurantoin
c. Ciprofloxacin
d. Gentamicin

ANS: A
Most antibiotics require dose adjustments in kidney disease. Some exceptions include azithromycin, cloxacillin, clindamycin, metronidazole, and erythromycin

*A 75-year-old patient will be discharged home with a prescription for an opioid analgesic. To help the patient minimize adverse effects, what will the nurse recommend for this patient?

a. Sucking on lozenges to moisten oral mucosa

b. Taking an antacid with each dose

c. Taking the medication on an empty stomach

d. Using a stool softener

ANS: D
Opioid analgesics can cause constipation. Stool softeners can help minimize this effect. An important component of planning for this patient would be identifying measures to prevent constipation with this new therapy.

A 75-year-old patient is readmitted to the hospital to treat recurrent pneumonia. The patient had been discharged home with a prescription for antibiotics 5 days prior. The nurse admitting this patient will take which initial action?

a. Ask the patient about OTC drug use.

b. Ask the patient how many doses of the antibiotic have been taken.

c. Discuss increasing the antibiotic dose with the provider.

d. Obtain an order for a creatinine clearance test.

ANS: B
There are many reasons for non-adherence to a drug regimen in an older patient, so if a patient is readmitted, the nurse should first ascertain whether or not the medications have been used. Asking the patient how many doses have been taken will help to assess this. If it is determined that the patient is taking the drug as ordered, the other steps may be taken.

*The nurse is performing an admission assessment on an 80-year-old patient who has frequent hospital admissions. The patient appears more disoriented and confused than usual. Which action by the nurse is most appropriate at this time?

a. Asking about medications and doses

b. Asking for a neurologist consult

c. Requesting orders for LFTs

d. Suspecting impaired renal function

ANS: A
An initial sign of drug toxicity in elderly patients may be confusion or changes in behavior. The nurse should ask about medication use (including OTC and herbal product use) and doses taken and notify the provider of the behaviors. The provider may order further evaluation based on the examination of the patient.

An older patient takes ibuprofen for arthritis pain. The patient tells the nurse that the ibuprofen causes GI upset. Which action will the nurse take with this patient?

a. Ask the provider about having the patient take a different medication.

b. Instruct the patient to cut the ibuprofen dose in half to avoid GI upset.

c. Explain that all drugs have adverse effects.

d. Explore options to help decrease the drug side effects

ANS: D
Older adults are more likely to experience drug side effects, and nurses should be aware of the measures that may decrease these side effects and thus improve adherence. The nurse would additionally want to ask follow-up questions to be sure the patient is experiencing additional symptoms that may indicate a GI bleed.

The nurse is caring for a 78-year-old patient who lives independently. The patient will begin a new drug regimen that requires taking multiple drugs at various times per day. Which intervention is appropriate for the nurse to implement with this patient?

a. Ask the patient’s family members to monitor the patient’s drug regimen.

b. Develop a log and/or calendar to record the times each drug will be taken.

c. Reinforce the need to take the drugs as scheduled.

d. Write the medication administration times on each prescription label.

ANS: B
The patient should be advised to keep a medication record of drugs and when they will be taken. The patient is independent, and this helps maintain independence. Family member support is essential when older patients are confused. Reinforcing information without providing a means to keep track of the medications does not necessarily improve compliance. Writing medication times on prescription labels does not help to organize the medication schedule.

*The nurse is preparing an 80-year-old patient for discharge home from the hospital. The patient will receive several new medications. The patient lives alone but has several family members who stop by every day. The patient reports problems with manual dexterity and difficulty with childproof medication bottles. Which suggestions will the nurse make for this family? (Select all that apply.)

a. Ask the pharmacy for non-childproof medication bottles.

b. Ask the patient to record all medications and the times they are taken.

c. Consider placing the pills in an organizer container.

d. Provide the patient with the drug manufacturer information sheets.

e. put the water bottles near pills for convenience

ANS: A, B, C, E

To help older patients with compliance, medications should be convenient and easy to open. Asking the pharmacist for non-childproof containers will help make medications easier to access since the patient has reported difficulty with childproof medication bottles. Using an organizer container helps patients remember which drugs should be taken at what time. Keeping a record of the drugs and when they are to be taken can also increase adherence. Placing water bottles nearby eliminates a step in the process and increases the likelihood that a medication will be taken on time. Providing the patient with the drug manufacturer’s information sheets is not needed for adherence; this level of information is not intended for the older consumer.

*Which drug properties are potentially problematic for older patients? (Select all that apply.)

a. Drugs with anticholinergic effects

b. Drugs that are highly protein-bound

c. Drugs with a short half-life

d. Drugs that undergo hepatic conjugation

e. Drugs with a narrow therapeutic range

ANS: A, B, E
Older patients are more susceptible to drug side effects, especially those that cause anticholinergic effects. Older patients have a loss of protein-binder sites for drugs, so those that are highly protein-bound will have higher than usual serum levels and can cause toxicity. Drugs with a narrow therapeutic range require closer monitoring in all patients, but especially in older patients. Drugs with a short half-life are preferred because older patients have a decreased ability to metabolize and excrete drugs. Hepatic conjugation is usually not influenced by older age, liver diseases, or drug interaction.