Exam 5- ch 33 (care for the older adult)

programmed aging

cells in the body can reproduce only 40-60 times; aging occurs when cells can no longer regenerate

genetic factors

people inherit a genetic program that determines their specific life expectancy

immunologic

immune system becomes less effective or less able to distinguish between foreign and host cells; aging results from diminished protection from infection or disease and immune system destroying body's cells that it recognizes as foreign

free radical

metabolic activity of the body produces energy, extra electrons are released that build up and combine chemically, damaging cells and interfering with normal body function

wear and tear

cells of the body wear out from internal and external stress (i.e. chemical damage, trauma, dysfunction of the body systems, buildup of waste)

erikson’s developmental stages

in the last stage of life, the task is acceptance of life and one’s own lifestyle which results in ego integrity (inability to achieve acceptance leads to anger and despair)

disengagement theory

older adults and society gradually withdraw from each other to the mutual satisfaction of both

exchange theory

reduced interaction between older adults and society as a result of decreasing value of the interaction

activity theory

older adults develop a positive concept of self as a result of maintaining social interactions (well-being in later life is enhanced when a person has a purpose- i.e. family, recreation)

continuity theory

personality remains the same, and behavior becomes more predictable

social security act of 1935

the first major legislation to provide financial security for older adults

older americans act of 1965

preserved rights and dignity of nation’s older citizens

patient protection and affordable care act of 2010

encourages payment for preventative services to medicare recipients and provides drug discounts for eligible seniors

sandwich generation

caring for their parents and their own children- 44 million caregivers to the elderly in the US and 75% are employed

s/s of depression in older adults

fatigue, sadness, insomnia, anorexia, helplessness, crying, agitation, and hypochondria

patient self-determination act of 1991

advanced directives, living wills, durable powers of attorney, and DNR orders

integumentary - age-related changes

-skin is dry and thin

-loses tone and elasticity

-loss of fat causing wrinkles

-aging spots

-hair greys and thins

-nails grow slowly and become thick and brittle

-slow wound healing

Pruritus

dryness and itching of the common

-use soap sparingly

-SNF have showering schedules- other days partial baths

-less frequent bathing recommended

-use water based lotions- NOT alcohol based

moles

most are benign; malignancies can develop in sun-exposed areas

nail abnormalities

clubbing of the fingers indicates possible pulmonary or cardiac disease

-yellow nails can indicate fungus

-splintered nails can indicate malnutrition

-brittle nails can occur during menopause

pressure injury

significant risk for older adults with chronic disease

-thin skin and lack of fat predispose older adults

GI in the older patient

-decreased secretion of saliva and gag response

-decrease gastric motility and slower peristalsis

-decreased production of intrinsic factor- unable to use ingested vit b12 (pernicious anemia)

-liver function decreases- metabolism less efficient

GI assessment

-assess mouth

-assess bowel movements/patterns/continence

-assess for abdominal tenderness

-annual f*cal occult blood test

obesity

-weighing at least 20% more than ideal body weight

-1600-2400 calories daily

-vit A, C, E and niacin can help slow aging process (don’t recommend ADEK- fatsoluble and can get sick)

weight loss

gradual weight loss over time is a normal response to loss of body mass

-decrease nutrient intake and appetite, lower metabolic rate and diminished energy output = weight loss

-rapid weight loss can indicate illness

-weight loss totaling more than 5% of weight in 6 months-1 year requires medical evaluation

fluids and dehydration

fluids are necessary to remove waste products of metabolism from the body

-older person needs 1500 mL of fluid daily

-create a toileting schedule every 2 hours while awake and ever 4 hours while asleep

oral hygiene

-loss of teeth is NOT normal for older age

-missing teeth can make chewing difficult

loss of appetite

results in decreased saliva production and decreased number of taste buds

-loss of smooth muscle → slower gastric motility → delayed emptying time, distention, and early feeling of fullness

-medications can produce undesirable side effects

gastric reflux

occurs when sphincter at the opening to the stomach becomes less efficient, which allows food and digestive enzymes to flow back into the esophagus

-s/s: heartburn, sour stomach, regurgitation

-recommend eating small meals, not eating right before bedtime and elevating HOB

-maintaining ideal body weight can help

food intolerance

lactose intolerance

-dairy products are an important source of calcium

-may need to replace milk with cheese and yogurt (processed and easier to eat)

dysphagia

difficulty swallowing

-causes can include: stroke, neurologic dysfunction, local trauma

-assess what occurs with (liquids, firm foods)

-interventions: avoid liquids, positioning, verbal coaching

failure to thrive

characterized by refusal to eat, loss of weight and lean body mass, and subsequent malnutrition

-associated with metal disorders such as dementia and depression; sometimes social and economic factors play a part

specialized nutritional support

inability to ingest, digest, or absorb nutrients can be an indication for enteral tube feedings

-place in stomach or small intestine

-standard enteral formulas contain whole proteins and complex carbs

-other formulas can include modified proteins or amino acids

-sometimes used short term post surgery; long term feeding poses risk

gastrointestinal cancer

requires medical attention: change in bowel or bladder habits, persistent oral lesions, visible or occult blood, indigestion or dysphagia, unexplained weight loss, constipation or persistent bloating

-assess for intake of fiber and fluids, meds, antacids, iron, anticholinergics, overuse of laxatives

-assess for mechanical obstruction, activity and exercise, limitations

fecal incontinence

most common cause in older adults- fecal impaction associated with immobilization and inadequate fiber and fluid intake

-cancer, IBD, colitis and neurologic disease can be a cause

gastrointestinal bleeding

-less protective mucous secretion=more susceptible to GI bleed

-assess for blood in stools, presence of dizziness, pallor, tachycardia, hypotension

-rectal bleeding can be a sign of hemorrhoids, rectal fissures, or cancer

what can yield a false-positive guaiac result

laxatives, iron supplements, anticoagulants, aspirin, NSAIDs, and red meat

GU system changes in older adults

-bladder capacity decreases 50% with age - some bladders can only hold 150 mL of urine

-decreased bladder tone can cause residual urine - causes sensation of full bladder in a short amount of time

-UTIs can trigger incontinence (first sign is confusion)

-incontinence is NOT a normal part of aging

-intercourse for women can become painful

-men can experience enlarged prostates- obstruct urine flow

GU assessment

-assess frequency, amount, color, odor, and consistency

-assess ability to control urination

-assess satisfaction with sexuality and affectionate relationships

nocturia

urination at night

-does not jeopardize physical health but interferes with sleep and can cause fatigue

-limit fluids in the evening

-give diuretics in the morning

-can indicate infection

urinary incontinence

-stress, urge, functional, overflow

-tx options: pharmacology, surgery, urethral stents, bladder retraining, kegel exercises

cardiovascular system changes in older adult

-loss of structural elasticity-chambers are less elastic, heart takes longer to contract, chambers take longer to fill

-heart valves becomes thicker and more rigid

-decrease in pacemaker cells→ dysrhythmias

-resting heart rate decreases

-blood vessels become less elastic, are lined with deposits, and HTN and arteriosclerosis occur

stroke death

a growing problem for the african american community (rate of stroke is twice that of caucasians)

-more than 44% of African Americans have cardiovascular disease

cardiovascular assessment

-difficulty breathing by exertion

-cough onset and duration

-pallor, flushed skin, cyanosis, edema

-chest pain (onset, duration, character, location, severity)

-pulses and cap refill

-presence of vertigo, syncope, fatigue

-blood pressure

hypertension

-contributes to CAD and development of heart failure, renal failure, and peripheral vascular disease

-pharmacologic treatment in ages 60+ has greatly decreased incidence coronary events

coronary artery disease

arteries that supply blood to your heart muscle becomes blocked or narrowed

-elevated serum cholesterol is a major risk factor

-do not consume more than 200 mg of cholesterol/day

-decrease saturated fat

-20-30 mins, 3-5x/week exercise

-walking is the best aerobic exercise for older adults

dysrhythmias

changes in the structure of the heart, the blood supply to the heart, and the pacemaker system make the heart more susceptible to irregular heart rhythms

-cause heart to be less effective in supplying blood to the body and can lead to heart failure

-nursing interventions: check vitals, note rate regularity and strength of pulse, monitor I&Os, observe and report response to activity

peripheral vascular disease (PVD)

vascular changes affect veins and arteries

-spasms and atherosclerosis cause insufficient amounts of oxygenated blood to tissues in legs and feet

-cause cold feet, numbness and intermittent claudication

-varicose veins are caused by failure of the valves to close adequately d/t distention and weakening of venous walls

-nursing intervention: promote circulation by walking, not crossing legs, compression stockings

Atherosclerosis

fatty deposits (plaque) build up inside your arteries, making them narrow, stiff, and less able to carry blood

Respiratory system changes in older adults

-tissue of the lungs and bronchi become less elastic and more rigid

-ribs become less mobile

-osteoporosis and calcification of cartilage lead to rigid thoracic cage

-oxygen-carrying capacity diminished

-muscles weaken so lung expansion and vital capacity are decreased

-decrease number of cilia

-kyphosis- air exchange is reduced because chest wall is less able to expand; residual air causes barrel chest

respiratory assessment

-depth, rhythm and rate of respirations

-inspect chest for shape and symmetry, body position and use of accessory muscles

-adventitious breath sounds

-activity tolerance

-ask pt to evaluate breathlessness on a scale of 1-10

-presence of cough and note characteristics

COPD (chronic obstructive pulmonary disease)

not a single disease, but commonly a combination of chronic bronchitis, chronic asthma and emphysema

-smoking history increases risk of debilitating COPD

-diminished breath sounds, crackles, wheezes and a barrel chest

-pursed lip breathing can help empty the lungs of used air

pneumonia

age-related changes and decreased resistance to respiratory infections cause more older individuals to contract and die

-s/s: lethargy, disorientation, anorexia, and low or mild fever

-nursing interventions: liquefy secretions, teach proper coughing technique to improve airway clearance

lung cancer

leading cause of cancer deaths

-risk factors: use of tobacco or marijuana, vitamin A deficiency, talcum powder

-most common form is SCLC which can metastasize to CNS, bones or liver

-often no s/s but can include: cough, chest pain, hemoptysis

-stage I treatable with surgery, stage IV requires palliative care

musculoskeletal system changes in older adults

-gradual reduction in number and size of active muscle fibers; decreased muscle tone, mass and strength

-joints are less elastic and flexible

-decreasing estrogen levels cause bone resorption→bone loss

-narrowing of intervertebral spaces

-shift in center of gravity, change in gait, increased risk of fractures

musculoskeletal assessment

-active and passive ROM

-joints for edema, erythema, pain and crepitus

-ability to perform personal care

-ability to perform activities- ask about previous fall history/traumatic injuries

-standing and gait

-limping, numbness or tingling, deformity

-muscle weakness, paralysis, tremors, spasms, clumsiness, muscle wasting and aches

arthritis

-rheumatoid and osteoarthritis

-affects functional ability and lifestyle

-nursing interventions: joint protection and energy conservation, ROM, heat and cold therapy, gentle massage, NSAIDS

hip fractures

can be open or closed fracture

-immobilization of joint is necessary

-s/s: tenderness and severe pain, edema, muscle spasm, deformity, bleeding, loss of function

-nursing interventions (after surgery): monitor mental status, assess movement, circulation and sensation

-keep affected extremity in alignment

-use pillows between knees or abduction splint

what are the most frequent fractures among older adults

hip, vertebral, clavicular

osteoporosis

systemic skeletal disease that is most common in older women

-low bone mass and deterioration of bone tissue→ increased risk of fractures

-kyphosis can develop- dowager’s hump

-diet high is calcium and vit D

-avoid smoking and excessive alc intake; limit caffeine

how much calcium and vit D do older women need?

1200-2000mg of calcium and 600-800 IU of vit D

endocrine system changes in older adults

-levels of hormones secreted and response of body tissue to hormones changes with age

-always assess lab results and report abnormal serum levels of calcium, glucose or thyroid hormone levels

type II diabetes

characterized by body’s inability to produce and use insulin appropriately

-s/s in the older adult: repeated infection, slow healing, blurred vision, weight gain or loss

-peripheral neuropathy increases with age

hypothyroidism

-s/s: unexplained elevation in triglycerides or plasma cholesterol, nonspecific cognitive impairment, slow metabolism, chest pain, atrial fibrillation, constipation, cold intolerance, depression

-goal is stabilization of thyroid levels with levothyroxine

reproductive system changes in older adults

-decreased estrogen and progesterone

-diminished levels of androgen and testosterone in men

-diminishes sexual function; changes in arousal, orgasm

-takes longer for men to be sexually aroused and achieve erection and ejaculation

-decrease in vaginal secretions, and pH becomes more alkaline

reproductive system assessment

-assess past experiences or difficulties and STIs

-assess signs of vaginal or penile ulceration, edema or discharge

-assess for presence of lumps, dimpling, or drainage from the breast

sexual function

-suggest use of estrogen creams or water-soluble lubricants to relieve discomfort

-lack of sexual partner is the main reason for decreased sexual activity

-positive correlation between sexuality and health

sensory changes with aging

-decreased number of eyelashes

-decreased tear production

-increased discoloration of lens

-decreased tissue elasticity

-decreased muscle tone of eye

-decreased number of papillae on tongue

-decreased number of nasal sensory receptors

vision changes in the older adult

-pupil is reduced in size causing difficulty acclimating to light changes

-muscles of eye become less effective

-telling similar colors apart becomes a challenge

-tear production lessened

-some clouding of the lens of the eye

-depth perception distorted

-blindness is NOT a normal part of aging

glaucoma

-caused by an occlusion in the drainage of fluid in the anterior chamber of the eye→ increases in intraocular pressure

-pressure transfers to optic nerve

primary open-angle glaucoma

-most common

-has capacity to reduce vision so gradually and painlessly that a person is unaware until optic nerve is damaged

-visual loss begins with deteriorating peripheral vision

acute angle-closure glaucoma

-occurs suddenly

-result of complete occlusion in the path of the aqueous humor

-s/s: severe eye pain, erythema, clouded or blurred vision, nausea and vomiting, rainbow halo surrounding lights, pupil dilation, and steamy appearance of cornea

cataracts

clouding of the normally clear, transparent lens of the eye

-degenerative changes to the lens protein and fatty deposits in lens

-lens becomes so opaque that transmission of light to the retina becomes impossible- creates blurry image

-s/s: dimmed, blurred, or misty vision, need for brighter light to read, sensitivity to glare and light

hearing and balance

-hearing loss caused by atrophic changes of the auditory nerve and end organs of the inner ear

-exposure to loud noises causes hearing loss of different tones

-cerumen impaction is reversible

categories of hearing impairment

-conductive: interruption of transmission of sound through external auditory canal and middle ear (i.e. cerumen impaction, otitis media)

-sensorineural: when inner ear, auditory nerve, brainstem or cortical auditory pathways do not function properly- sound waves not interpreted correctly

-mixed hearing loss: conductive hearing loss superimposed on a sensorineural hearing loss

Presbycusis

moss common form of hearing loss in older adults; sensorineural; cause unclear

-loss is bilateral

-difficulty hearing high-pitched tones and conversational speech

-s/s: increasing volume on tv, tilting head toward person speaking, cupping a hand around one ear, not responding when spoken to

-tx: cochlear implant, hearing aids, auditory rehabilitation

touch smell and taste

-gives tactile information- pressure, vibration, temperature

-decrease in number of receptor cells through skin and joints

-difficulty sensing temperature and maintaining balance

-disorders that affect tactile ability: stroke, PVD, diabetic neurpathy

-olfactory receptors decline; decrease in tastebuds

assessment of sensory organs

-eyes for dryness, tearing or signs of irritation

-ability of individual to see close up/at a distance

-hearing

-reported changes in taste or smell

decreased vision

-be sure patient eyeglasses are clean and available

-increase amount of light in environment

-reduce glare with uses of shades on windows and lights

-use nightlights

-use large prints, strongly contrasting colors, magnifying glasses

decreasing hearing

-hearing aids do not compensate for nerve damage or effectively screening out distracting noises

-face individual when speaking and speak at a normal tone and pace

-eliminate background noises when possible

-use nonverbal communication

older adults nervous system changes

-decline in number of brain cells and peripheral nerve cells and fibers

-synaptic changes that affect transmission and sensitivity of target cells to neurotransmitters

-nerve impulse transmission slows

-autonomic nervous system- decreasing efficiency in maintaining normal body temperature and pulse returning to normal after exercise or stress

-changes in sensorimotor and motor function, memory, cognition, sleep patterns, and proprioception occur at different rates

memory of the older adult

-changes in short term memory are common with aging

-long term memory is maintained

cognitive function

process by which memory is acquired, stored, shared, and used

-outcomes: remembering, perceiving, communicating, and calculating

-intelligence and continued ability to learn is possible throughout the lifetime

-modify teaching strategies to accommodate the older adult

sleep

-can mean difficulty falling asleep or staying asleep

-can be disease-related or psychological

-medications such as diuretics and corticosteroids can cause awakening to urinate

-alcohol and drugs can interrupt sleep

-intake of stimulants

proprioception

-ability to maintain and upright position without falling

-depends on ability to use balance, posture and movement

-aging results in slower reflexes, diminished strength of muscles for posture, and increased postural sway

-damage to inner ear can affect balance

-ability to achieve proprioception declines with age

personality

-personality remains stable during aging

-signs of impaired emotional control, diminished initiative, or withdrawal can indicate initial sign of brain dysfunction

neurological assessment

-LOC

-appropriateness of behavior and responses

-mental status (orientation, memory, attention, language and motor skills)

-pain (severity, location, quality, duration)

-sleep patterns

-lab results for electrolyte imbalance, anemia, liver function, drug levels, vitamin B12

-assess CT scan or MRI for tumor, subdural hematoma, stroke

insomnia

-sleep patterns changes with age

-encourage a bedtime ritual

-promote environment conducive to sleep

-exercise and activity during the day

-avoid caffeine and excess fluids before bed

-sleep aids can be habit forming can lead to falls during the night

delirium

Senility is the state of mental and physical deterioration associated with aging

-delirium is reversible; it is a syndrome, not a disease

-s/s: restlessness, agitation, appearing withdrawn, personality changes, mood shifts

-causes: fever/infection, dehydration/malnutrition, electrolyte imbalance, sleep deprivation, alcohol or drug use, pain, meds, inadequate oxygenation to the brain

dementia

a progressive impairment of intellectual function; brain atrophies

-s/s: loss of memory and at least one other disturbance of intellectual function (i.e. orientation, attention, calculation, language, motor skills)

-affects short, intermediate, and long term memory

-difficulty with abstract thinking, agnosia, aphasia, apraxia, agraphia

-alzheimer disease is the most common form

stages of demetia/alzheimer disease

-early stage: gradual onset of memory loss and difficulty focusing attention

-middle stage: difficulty with language, object recognition, and judgement

-terminal (final) stage: urinary and fecal incontinence, inability to ambulate or provide self care, inability to communicate- patient becomes mute and bedridden with no recognition of family members

-average duration of illness is 8 years- can last 20 years

Multi-infarct dementia

MID or vascular dementia

-interruption of blood flow to the brain- multiple strokes occur

-can result from stroke and severe HTN

-patient can have periods of remission, preservation of personality, mood swings

-risk factors: arteriosclerosis, blood dycrasias, cardiac decompression, HTN, atrial fibrillation, heart valve replacements, DM, PVD, smoking

-symptoms depends on location of infarct

-s/s: abrupt onset of confusion, wandering, getting lost in familiar places, rapid-shuffling steps, loss of bladder and bowel control

other dementia related diseases

-huntington disease

-creutfeldt-jakob disease

-HIV-associated dementia

parkinson disease

progressive and degenerative- muscle rigidity, tremors, akinesia (abnormal state of motor and psychic hypoactivity)

-masklike appearance, drooling, shuffling gait, emotional instability

-medications can help slow the process

-nursing interventions: observe response to meds, maintain mobility, ROM, remove throw rugs and other fall hazards, install handrails and good lighting

-intellectual function is not impaired but communication is difficult

transient ischemic attacks

small spasms or occlusions in the cerebral vessels of the brain

-s/s: changes in vision, headache, disorientation, ataxia, drop attacks (falling without losing consciousness)

-can last as little as 20 mins

-1 in 3 have a stroke within 5 years

-prophylactic interventions can help prevent stroke

stroke

CVA- 5th leading cause of death in the US

-risk factors: CAD, DM, physical inactivity

-s/s: hemiplegia, dysarthria, dysphagia, sensory changes, aphasia, intellectual and emotional changes

-nursing interventions: rehabilitation to accomplish ADLs and be independent, teach use of non-dominant hand, use assistive devices, encourage exercises given by PT

polypharmacy

use of give or more medications (prescribed or OTC)

-every med has a risk for adverse side effects

-drug-to-drug interaction can occurs

-body’s ability to absorb, transport, metabolize, and eliminate meds declines with age

elder abuse and neglect

-five classifications: physical or sexual abuse, misuse of assets, medical abuse, neglect

-monitor for older person’s frequent unexplained crying and older person’s fear or suspicion of a particular person in the home