GERIA MIDTERMS

SENSORY CHANGES

occur naturally with age but other factors may contribute such as functional impairment, injury, social isolation, & depression

NORMAL AGE-RELATED CHANGES TO EYE

• occur gradually but limits functional ability 

• external changes  

• graying and thinning eyebrows and eyelashes  

• subcutaneous tissue atrophy → wrinkling skin surrounding eyes  

• decreased orbital fat → sunken eye + sagging eyelids

cornea and lens changes

• less endothelial cells on cornea → reduced ocular sensitivity = decreased pain response

• lipid around peripheral cornea → arcus senilis 

• lenses thicken + harden  

yellowish appearance + opacity

• difficulty identifying blue, green and violet

light to scatter

• interfered color discrimination  

reduced space for drainage of aqueous humor

• glaucoma  

impedes accommodation

presbyopia

pupil  changes

• decreased dilation and constriction  

• delayed response → difficulty responding to light  changes

• decreased diameter → decreased light reaching diameter

iris  change : loses color

• eyes gray or light blue  

visual acuity changes

• diminishes gradually after 50 yo. & decreases rapidly after 70  yo.

light sensitivity declines with age

• brightness contrast, decreased peripheral vision, diminished night vision = decreased dark adaptation, recovery from glare, & decreased sensitivity to glare 

EYE INTERVIEW

• to know date of last exam, and test vision adequacy (movement of eyelids), recent changes in vision, & visual problems 

• red eye 

• excessive tearing or discharge 

• headache 

• eyestrain when reading or doing close work 

• foreign body sensation in the eye

• new onset of double vision or rapid deterioration, haziness, flashing lights, or moving spots 

• loss of central or peripheral vision 

• trauma or eye injury 

• abnormally colored sclera 

• abnormal / absent papillary response

EYE VISION

• by snellen chart or reading from print, visual field testing, & extraocular movements 

• visual aids (often rejected because of stigma attached & very expensive, not covered by medicare)

• low-vision clinics for suggestions

• telescopic lenses 

• books in braille

• computer scanners and readers

• tinted glasses to reduce glare, large print books and magazines

• seeing eye dogs 

• canes 

register with commission for the blind

• books on tape and tape player 

• telephones with large numbers 

• high-intensity lights

assessment of vision

• observe appearance 

• clothing cleanliness 

• self-care 

• bumps and bruises

visual acuity

•  always start with right eye to ensure accurate recording and cover the eye not being tested with an occluder 

• 20/20 at 6 y/o 

• numerator = 20 ft (distance person stands from chart) 

• denominator (distance from where normal eye can read the chart) 

healthy older adults

• complete eye examination every 1-2 years  (visual acuity, retina, & intraocular pressure)

diabetics patient

complete eye examination annually

VISUAL IMPAIRMENT

• visual acuity 20/20 by snellen chart at 20 feet (increases with age); linked with 4 causes : cataracts, macular degeneration, glaucoma, & diabetic retinopathy 

• results to loss of independence, social isolation, depression, & decreased life quality

legal blindness

• visual acuity 20/200 by snellen chart at 20 feet (increases with age and peaks at 85 yo.)

visual difficulties limiting independence

• interfering with ability to drive, read, and write

s/sx of vision difficulty

• squinting or tilting head to see 

• changes in ability to drive, read, watch television, or write 

• holding objects closer to the face & difficulty with color discrimination and walking up or down stairs 

• hesitation in reaching for objects & not being able to find something (American Society on Aging, 2003)

evaluate functional ability  to :

• perform activities of daily living (ability to read medication labels)

• drive or take public transportation 

 

• ambulate safely in familiar and strange environments  

• shop and pay for food and personal items  

• prepare food in safe and hygienic environment  

• engage in recreational and leisure activities

CATARACT

opaque crystalline lens or its capsule (partial or complete)  by injury, trauma, exposure to heat / UV light, heredity / congenital, aging (55+) / senile, diabetes mellitus secondary, and smoking & alcoholism

• development slow and painless

lens clouding → decreased light to retina =  limited vision

leading cause of blindness in the world = 50% of 65 years+ have cataracts → visual problems

cataract risk factors

• increased age 

• smoking and alcohol 

• diabetes

• hyperlipidemia 

• trauma to the eye 

• exposure to sun and UVB rays

• corticosteroids 

cataract symptoms

• blurred vision with glare 

• halos around objects 

• double vision 

• lack of color contrast / faded colors 

• poor night vision

CATARACT : EDUCATION

• cataract tx. = surgery

• stop smoking and avoid lifting heavy objects, straining at stool, and bending at waist

• wear hats & sunglasses when in sun and avoid ocular injury (eye drop administration)

• low fat diet

phacoemulsification (small incision cataract surgery)

small incision outside cornea by tiny probe inserted which emits ultrasound waves softening & breaking lens to be removed by suction

extracapsular / intracapsular cataract surgery

incision longer on the side of cornea & removes cloudy core in one piece & the rest of the lens is removed by suction

GLAUCOMA

• increased intraocular pressure (IOP) → optic nerve damage = vision loss 

• risk factors : 60+ yo, family history, personal history of myopia / diabetes / hypertension / migraine, and ancestors of African American

open angle glaucoma

• slowed flow of aqueous humor through trabecular meshwork → build up→ increased IOP → damage to renal nerve fiber = loss of vision 

• painless vision loss in  midperipheral visual field 

open angle “normal-tension” glaucoma

• normal IOP but still damaged optic nerve → visual changes 

• s/sx : enlarged optic cup, nicking neuroretinal rim, & small hemorrhages near optic disc

angle closure glaucoma

• angle of iris obstructs drainage of aqueous humor through trabecular meshwork → increased IOP = visual changes 

• s/sx : unilateral headache, visual blurring, nausea and vomiting, & photophobia

miotics : pilocarpine (carbachol)

• contracts ciliary muscles & constricts pupil 

carbonic anhydrase inhibitors : acetazolamide (diamox)

• promotes increased outflow of aqueous humour 

GLAUCOMA : NURSING CARE

• explain importance of continued use of eye medications to prevent further visual loss

• explain need for continued medical supervision for observation of IOP to ensure control 

• teach client to avoid exertion, stooping, straining for a bowel movement, coughing, heavy lifting, or wearing constricting clothing = increased IOP 

• instruct the client to report severe eye / brow pain & nausea

prevent diabetic retinopathy by :

• tight glycemic control (average postprandial = 80 to 120 mgm/dl & bedtime capillary blood glucose = 100 to 140 mgm/dl) and HbA1c less than 7 

• manage hypertension & hyperlipidemia with proper nutrition of low-carbohydrate diet & low-cholesterol diet and exercise

ARMD risk factors

• 50+ yo. 

• cigarette smoking & family history

• exposed to UV light

• Caucasian and light colored eyes

• hypertension / CVD

• lack of dietary antioxidants & zinc

other ARMD s/sx

• difficulty performing tasks with close central vision (reading and sewing)

• decreased color vision and dark or empty area in center of vision (central scotomas)

• straight lines appearing wavy and crooked (metamorphopsia)

• words on a page looks blurred

dry ARMD (atrophic form)

• involutional macular degeneration / breakdown or thinning of macular tissue related to aging process  / atrophy  / retinal pigment degeneration  / drusen accumulations  

• slow progression of visual loss

wet ARMD (neovascular exudates)

• exudative macular degeneration where blood or serum from new blood vessels beneath retina → scar formation + visual problems 

• s/sx : more light for reading, blurred vision, central scotomas, & metamorphopsia

AGE RELATED MACULAR DEGENERATION (ARMD) : PREVENTING MEASURES

• wearing UV protective lenses in sun and cease smoking 

• exercising routinely & eating healthy diet (fruits and vegetables)

• vitamins in divided doses BID to delay progression  

• zinc oxide 80 mgm  

• cupric oxide 2 mg  

• beta carotene 15 mgm  

• vitamin C 500 mgm  

• vitamin E 400 IU

ABNORMAL CHANGES TO EYE : IDENTIFYING SAFETY PROBLEMS AT HOME

• adequate lighting in high-traffic areas and motion sensors to turn on lights; proper lampshades to prevent glare 

• use contrast when painting = walls, floors, and other environment can be discriminated easily and avoid reflective floors

• hot colors (red, orange, and yellow) for signage; red colored tape or paint on  edges of stairs and entryways to provide warning and signal the need to step up or down

• avoid complicated rug patterns = overwhelms the eye and obscure steps and ledges

• importance of walking slowly when entering a room

external ear

• auricle wrinkles and sags

• increased cerumen production : dry → pruritus and hard; decreased apocrine gland activity → accumulation

inner ear

• atrophied Corti and cochlear neurons 

• loss of sensory hair cells 

• degenerated stria vascularis

HEARING LOSS

• affects less 30% (65-76 yo) and more 50% (75+ yo) in older Caucasian men than African American people

• hearing loss assessment : 

• history & talk with family

• physical examination  

• childhood ear infections → ruptured eardrum = jagged white scars on tympanic membrane 

• hearing handicap inventory for the elderly (HHIE-S) 

hearing loss risk factors :

• long-term exposure to excessive noise 

• impacted cerumen (ear wax) 

• ototoxic medications 

• tumors & diseases that affect sensorineural hearing 

• smoking 

• chemical exposure (long exposure to trichloroethylene)

sounds less than 75 dB(A)

temporary hearing loss

sounds more than 85 dB(A) for 8hrs/day chronically

• permanent hearing loss

HEARING LOSS : NURSING DIAGNOSIS

• ability to perform activities of daily living  (communication, driving or taking public transportation, safety awareness to hear alarms, doorbells, and engaging in leisure and recreational activities)

HEARING LOSS : CONDUCTIVE

• sounds unable to be transmitted in external / middle ear → poor reception + amplification; most commonly caused by impacted cerumen but reversible

• other conductive hearing loss causes : otitis externa, otitis media, benign tumors, perforated tympanic membrane, foreign bodies, & otosclerosis

HEARING LOSS : SENSORINEURAL (PERCEPTIVE / NERVE HEARING LOSS)

• pathologic changes in inner ear, 8th cranial nerve, and/or auditory centers of brain 

• sensorineural hearing loss caused by : 

• presbycusis (bilateral progressive hearing loss at high frequencies)

• high-frequency hearing loss from excessive noise (industrial noise, gunfire, rock & roll deafness)

TINNITUS (COMMON HEARING PROBLEM IN ELDERLY)

• pulsatile sounds with turbulent blood flow through the ear by hypertension, anemia, or hyperthyroidism

• patient perceives sound without sound stimulus due to medications, infections, neurological conditions, or disorders R/T hearing loss

CERUMEN REMOVAL PROTOCOL & IMPACTION

• clip and remove ear hairs and instill softening agent, mineral oil, carbamide peroxide or glycerin solution 

• irrigate ear using bulb syringe & use a solution of 3oz 3% hydrogen peroxide in 1 quarter water or PNSS (warmed to 98 to 100)

• place a towel around neck and tip head to side being drained has an emesis basin and place the tip of the irrigating device inside the external meatus with tip visible

• straighten auditory meatus draw pinna up and down = flow of irrigating fluid steady, lavage continues until cerumen is removed 

• drain excess fluid by tilting the head toward affected side and impacted cerumen must be manually extracted with otoscope and curette

NORMAL AGE-RELATED CHANGES TO TASTE

• diminished taste sense (2.5-5x) to determine protein, salt, and sweetness

• contributing factors to taste alterations : oral condition, olfactory function, medications, diseases, surgical interventions, & environmental exposure 

• focused assessment on head and neck, mucous membranes, & interview on past dietary habits

poor dentition

• improper chewing = less flavor release 

improperly fitting dentures

obstructed palate = decreased taste perception

oral infections

• release acidic substances = altered taste + impaired salivary stimulations → decreased ability for food to dissolve = diminished flavor

taste education :

• decreased taste → lack of motivation to prepare + eat = malnutrition

NURSING DIAGNOSIS WITH TASTE IMPAIRMENT (ALTERED GUSTATORY)

intake less than necessary for caloric requirements

olfactory dysfunction (affects males than females) caused by :

• nasal and sinus disease 

• upper respiratory infection 

• head trauma 

• secondary  chemotherapy or other medications, radiation, current or past use of cocaine or tobacco , & poor dentition

XEROSTOMIA

• caused by systemic diseases, radiation, medications, & Sjogren’s syndrome

• xerostomia causes : 

• altered taste 

• difficulty swallowing → risk for aspiration pneumonia 

• periodontal disease 

• speech difficulties → embarrassment = social isolation

• dry lips + dry mucosa → increased infection + dental caries = halitosis (bad breath)

• sleeping problems

NORMAL AGE-RELATED CHANGES TO SMELL

odors thresholds 11x for elderly

structural alterations contribute to loss of smell by upper airway, olfactory tract and bulb, hippocampus, amygdaloid complex, & hypothalamus

OLFACTORY DYSFUNCTION

• special concerns for safety R/T smoke and fire & malnourishment

• use 3 familiar smells repeated in both nostrils (in different orders) to adequately test sense of smell

OLFACTORY DYSFUNCTION : NURSING ASSESSMENT

• assess safety & preventive measures and nutrition

• date and label all foods  

• natural gas detectors (for gas heat)  

• smoke detectors 

• schedules for personal hygiene and house cleaning  

• remove kitchen waste every evening

OLFACTORY DYSFUNCTION : NURSING DIAGNOSIS

• R/T hyposmia : altered olfactory

• R/T physical sensations : tactile

NORMAL AGE-RELATED CHANGES TO TACTILE SENSATION

• diminished with age with decreased ability to detect extreme temperatures

SCOPE OF PRACTICE OF GERONTOLOGICAL NURSE

specialize in nursing care and health needs of older adults; plan, manage and implement health care & evaluate effectiveness

gerontological nurse primary challenges

• identify & use  strengths of older adults and assists them in maximizing independence 

• actively involve older adults & family in decision making process (great impact on everyday quality of life)

GERONTOLOGICAL NURSE ROLES

• provider of care 

• teacher/educator 

• manager 

• advocate 

• research consumer

CLINICAL GERONTOLOGICAL NURSING CARE STANDARDS

• STANDARD I. Assessment

• STANDARD II. Diagnosis

• STANDARD III. Outcome Identification

• STANDARD IV. Planning

• STANDARD V. Implementation

• STANDARD VI. Evaluation

CORE COMPETENCIES

• foundation of added knowledge and skills for nurse to implement in daily practice

• developed by AACN and the John A Hartford Foundation Institute for Geriatric Nursing “OLDER ADULTS: Recommended Baccalaureate Competencies and Curricular Guidelines for Geriatric Nursing Care” - guides to nursing professors to prepare students to be competent to provide excellent care

• critical thinking 

• communication 

• assessment 

• technical skills

CORE KNOLWEDGE

• health promotion, risk reduction, & disease prevention 

• illness and disease management 

• information & health care technologies 

• ethics 

• human diversity 

• global health care 

• health care system & policy

aging

• natural process common to all and  various factors influence the aging process

unique data and knowledge

used in applying nursing processes to the older; they share similar self-care and human needs

gerontological nursing

• strives to help older adults achieve wholeness by reaching optimum levels of physical, psychological, social, and spiritual health

ETHICS OF CARE

• 1 advocacy

• 2. autonomy

• 3. beneficence / nonmaleficence

• 4. confidentiality

• 5. fidelity

• 6. fiduciary responsibility

• 7. justice

• 8. quality and sanctity of life

• 9. reciprocity

• 10. veracity

ACTUAL CONFLICT OF INTEREST ISSUES

• between family members and caregivers who represent the elderly or assist them in decision making 

• between family members  / spouses and elder’s wishes and interest

• between a guardian, conservator or other lawfully designated agent and elder’s wishes and interests

• between caregiver’s business interests and elder’s interests well-being and quality of life

PERCEIVED CONFLICT OF INTEREST

• not actual conflicts in care but may later become conflicts with the elder

CONFIDENTIALITY ISSUE

caring for elderly patient - disclosure made by family and relatives regarding information that may otherwise be personal and confidentiality to the patient

DECISION-MAKING /  COMPETENCE ISSUE

• elderly’s competence may be required for certain decisions

GERONTOLOGIC NURSING LEGAL RISKS

• malpractice

• confidentiality

• patient consent

• patient competency

• staff supervision

• medications

• restraints

• telephone orders

• do not resuscitate orders

• advance directives and issues related to death and dying

• elder abuse

RA 7432

act to maximize contribution of senior citizens to nation building, grant benefits and special privileges and for other purposes

RA 8425

institutionalization and enhancement of social reform agenda by creating National Anti-Poverty commission (NAPC)

RA 344 or Accessibility Law of 1982

• minimum requirements and standards to make buildings, facilities, and utilities for public use accessible to persons with disability (older people confined to wheelchair and have difficulty in walking or climbing stairs)

RA 9994 / Expanded Seniors Citizen Act of 2010

• act granting additional benefits and privileges to senior citizens, further amending RA 7432 

RA 10155 / The General Appropriations Act of 2012

• under Section 28, mandates all government agencies and instrumentalities should allocate 1% of their total agency budget to programs and projects for elderly and persons with disability

RA 10645 / Act Providing For the Mandatory Philhealth Coverage for All Senior Citizens

• removing the qualification that a senior citizen has to be indigent before being covered by PhilHealth

RA 10868 / “Centenarians Act of 2016”

• act honoring and granting additional benefits and privileges to Filipino centenarians

Filipinos who have turned centenarian in the current fiscal year

shall be awarded a plaque of recognition and cash incentive by respective city or municipal governments with ceremonies and letter of felicitation and centenarian gift of P 100,000.00

Presidential Proclamation 470, Series of 1994

• first week of october as “ elderly filipino week.”  

Presidential Proclamation 1048, Series of 1999

• nationwide observance in the Philippines of the international year of elderly

EO 105, series of 2003

• approved and directed the implementing program providing for group homes and foster homes for neglected, abandoned, abused, detached, and poor older persons and persons with disabilities

The Philippine Plan of Action for Senior Citizens (2011-2016)

to ensure giving priority to community-based approaches (gender-responsive) with effective leadership and meaningful participation of senior citizens in decision-making in family and community

decreased body water (15%)

•  from increased water-soluble drug concentration (ex. alcohol)

increased body fat

• prolonged effects of fat soluble drugs

decreased blood flow

• leads to increased toxicity = increasing SGPT, PT, & PTT

MEDICATION RESPONSE PREDICTORS

• general state of health  

• number and types of other medications taken  

• liver (SGPT) , renal function creatinine  

• presence of comorbidities or other diagnosed

MEDICATION ERROR

• from human knowledge based deficiencies and lack of sophisticated systems to support and monitoring drug therapy