nursing care for older adults - part 2

Nutritional Needs for older adults

Increased calcium, vitamin D, and vitamin B12, decreased caloric intake, recommended daily value for sodium, and fluid intake

malnutrition effects

infections, pressure ulcers, anemia, hypotension, impaired cognition, and increased mortality and morbidity

Psychosocial Risk Factors for malnutrition

Limited income, misuse of alcohol, isolation & loneliness, depression, memory loss, and inability to partake in usual cultural patterns

Mechanical Risk Factors for malnutrition

Reduced strength/mobility, diminished vision, loss of teeth, chewing difficulties, shortness of breath, polypharmacy, and inability to grocery shop or prepare food

Assessment for Malnutrition

Interview, diet history, physical exam, and biochemical exam

Assessment for Malnutrition: Diet History

24-hour diet recall or 3-day dietary record

Assessment for Malnutrition: Interview

Current state of health, social activities, eating pattern, recent life changes, how food is obtained and prepared, occupation & daily activities, financial resources, medications, visual difficulties, bowel & bladder function, and mouth pain/ discomfort

Assessment for Malnutrition: Physical Exam

Height, weight, BMI, vital signs, condition of the tongue, lips, and gums, skin turgor, texture, and colour, functional ability, and general appearance

Assessment for Malnutrition: Biochemical Examination

albumin, cholesterol, and transferrin

Pharmacological Therapy

Appetite-stimulating medications which provide small weight gains & come with risk of side effects

Enteral Feeding

tube feeding

Dysphagia

difficulty swallowing

signs of dysphagia

Difficult, laboured swallowing, drooling, copious oral secretions, coughing or choking while eating, holding or pocketing food in the mouth, difficulty moving food or liquid from mouth to throat, difficulty chewing, nasal voice or hoarseness, and wet or gurgling voice

What are options for nutrition with dysphagia?

NPO diet, IV, therapeutic diet, NGT, G tube, or total parenteral nutrition

short term feeding tube

An NGT (nasogastric tube) is inserted through the nose into the stomach to provide nutrition and medications. It's easier to insert than long-term options but can be uncomfortable and still carries a risk of aspiration.

long term feeding tube

A G-tube or PEG (percutaneous endoscopic gastrostomy) is surgically inserted to deliver nutrition and medications directly to the stomach. Although it provides long-term support, the patient can still aspirate, and it may limit mobility. It also requires a dressing but has a lower-profile design for comfort and discretion.

Poor oral health is a risk factor for

missing teeth, teeth in ill repair, oral pain, chewing and swallowing problems, inadequate nutritional intake, and dehydration

Oral health risk factors

tobacco use, alcohol, and unhealthy diets high in free sugars

Barriers/Facilitators to Adequate Oral Health

Functional or cognitive limitations, access to dental care, access to fluoridated water, and cost of dental care

Xerostomia

dry mouth that can make eating, swallowing, and speaking difficult and can lead to significant problems of the teeth and their supporting structure

xerostomia interventions

artificial saliva preparations, maintaining adequate fluid intake, and chewing gum with xylitol to stimulate saliva production.

Oral Health: Nursing Assessment

Assess the lips, tongue, gums and tissues, saliva, and teeth/dentures and assess for oral cleanliness and dental pain

oral care and enteral feeding

oral care must be done every 4 hours for those with gastronomy tubes, and the oral mucosa should be kept hydrated and there is a possible effect on microbiome

Reasons for poor oral care in residential settings

Inadequate knowledge of how to assess and provide care, difficulty in providing oral care to dependent and cognitively impaired older adults, inadequate training and staffing, and lack of appropriate supplies

Urologist

specializes in diseases of the urinary system and are surgeons

Urogynecologist

a gynecologist with special training in urinary problems that affect women and are surgeons

Nurse continence advisor

assess/treat bladder problems and is specially educated in incontinence

Physiotherapist

can provide advice and information on how your bladder works and how to control leakage through behavioural treatments like Kegel exercises, biofeedback and bladder retraining

Anuria

absence of urine

polyuria

excessive urination

Dysuria

painful urination

Nocturia

excessive urination at night

Hematuria

blood in the urine

Pyuria

pus in the urine

Oliguria

Decreased urine output

Ketonuria

ketones in the urine

kidneys

lie on either side of the vertebral column behind the peritoneum and against deep muscles of the back

ureters

tubular structures that enter the urinary bladder obliquely through the posterior wall at the ureterovesical junction

urethra

tube leading from the urinary bladder to the outside of the body

micturition

urination

voiding

urination

left kidney

higher than the right one because of the anatomical position of the liver.

Urinary Incontinence

involuntary leakage of urine and is mistaken as a normal part of aging

Assessment (urinary elimination)

Health history, physical exam of skin, kidneys, and bladder, and urinalysis

Urinalysis

test for pH (4-6), protein, glucose, ketones, blood, and specific gravity in urinalysis and WBC, bacteria, casts, and culture

Risk Factors for Urinary Incontinence

increased age, immobility or limited mobility, dementia, certain medications that increase frequency or urgency, high caffeine intake, history of pregnancy and vaginal childbirth, and pelvic floor weakness

Transient (acute) UI

Sudden onset, present for less than 6 months, and may be secondary to treatable causes such as UTIs, delirium, metabolic conditions causing increase urination, bedrest, or certain medications

Established (chronic) UI

Lasts longer than 6 months and is further divided into subtypes

Urge incontinence

overactive bladder muscles create a sensation of urgency, and the individual is unable to suppress the urge to void before reaching BR

stress incontinence

involuntary loss of a small volume of urine when the intra-abdominal pressure increases

Urge or stress incontinence with a high post-void residual

When the bladder does not empty properly, it becomes overdistended and the individual experiences frequency, 'dribbling' of urine, and a feeling of incomplete emptying of the bladder

Functional incontinence

the lower urinary tract is functional, but the individual cannot reach the bathroom before of other factors, including environmental barriers, cognitive impairment, or physical limitations

Mixed incontinence

combination of more than one type and is usually stress and urge

Behavioural Interventions for Ui

scheduled voiding for urge and functional urinary incontinence, prompted voiding to remind or assist the person, bladder training for urge incontinence, and pelvic floor muscle exercises for urge, stress, and mixed incontinence

lifestyle modifications for Ui

drink more during the daytime/less after dinner, weight loss, and eliminate or reduce caffeine and alcohol consumption

Nursing Care for Patients with UI: Interventions

mobility, pharmacological, and behavioral and lifestyle modifications

Urinary incontinence is associated with an increased risk of:

falls, skin breakdown, pressure ulcers, urinary tract infections, anxiety and depression, social isolation, and avoidance of sexual activity

fecal impaction

the prolonged retention and buildup of feces in the rectum

fecal incontienence assessment

medical history, surgical history, current bowel habits, diet, medications, and physical assessment of the gastrointestinal tract

Risk Factors for Fecal Incontinence

increased age, loose bowel movements, bowel-related disorders, dementia, spinal cord injury, neurological conditions, and impaired mobility

Fecal Incontinence Prevention & Management

comprehensive assessment of bowel habits, diet, medications, and health history, psyllium fibre supplements, establish a bowel training program (fibre, fluids, exercise), take an interdisciplinary approach, ensure proper peri-care,and use bedpans and commodes

Constipation Prevention & Management

30-60 minutes of low-intensity physical activity at least 3 times per week, adequate fibre intake, adequate fluid intake, individualized bowel protocol, and identify triggers (e.g., meal/gastrocolic)

Cognitive health

thinking, learning, and remembering

Motor function

ability to control movements and balance

Emotional function:

ability to interpret and respond to emotions

Tactile function

ability to feel and respond to touch (pressure, pain, temperature)

Sensory function

ability to use the other sense (sight, hearing, taste, smell)

Depression, Dementia, and Delirium

not a normal part of the aging process. However, the incidence of these conditions do increase with age

Depression

a common neuropsychiatric symptom of dementia that causes severe symptoms that affect how a person feels, thinks, and handles daily activities, such as sleeping, eating, or working

Major depression

loss of interest in activities or depressed mood most of the time over the last 2 weeks, to the extent that symptoms impair everyday activities

what does depression affect?

physical and functional health, socialization, and quality of life

Predisposing factors of depression

brain chemistry, genetics, certain medical conditions (e.g. thyroid dysfunction), certain medications, social Isolation, history of depression, and widowed/divorced

Precipitating factors of depression

Recent bereavement, stressful life events, chronic stress, and persistent sleep challenges

S & S of Depression in the Older Adult

Does not get dressed, loss of interest in previously enjoyed activities, expresses consistent feelings of sadness, sleep dysfunction (too little or too much), eats more or less than typical, difficulty concentrating, lacks energy, difficulty remembering things, isoiates oneself, talks about self-harm or suicide, and somatic symptoms

assessment for depression

Patient interview, medical history, physical & cognitive assessment, medication review, family/caregiver review, and depression screening tool

how to improve depression

Regular physical activity, eating a nutritious diet, avoiding alcohol, social interaction with friends and family, and proper sleep hygiene

Consequences of Depression

Functional decline, delayed recovery from an illness, malnutrition, decreased quality of life, increased risk of substance use, and increased risk of suicide

Dementia

Neurocognitive Disorder that causes a slowly progressive decline in mental abilities, including memory, thinking, and judgment, that is often accompanied by personality changes

Early Signs of Dementia

Memory loss, misplacing items often, forgetting names of familiar things, repeating themselves without noticing, and hesitating to try new things

Typical forgetfullness

Making a bad decision, missing a monthly payment, forgetting which day it is, forgetting which word to use, and losing things from time to time

Atypical aging: Dementia

Poor judgments/decisions a lot of the time, problems taking care of the monthly bills, losing track of the date/time of yea, trouble having a conversation, and misplacing things often/unable to find them

alzheimers disease

a progressive and irreversible brain disorder characterized by gradual deterioration of memory, reasoning, language, and, finally, physical functioning

early symptoms of alzheimers

apathy, depression, memory loss, word-finding problems, vision or spatial issues, and impaired reasoning or judgement

Parkinson's Disease

Slowly progressing neurologic movement disorder that eventually leads to disability

Vascular Dementia

Consists of a group of heterogeneous disorders arising from cerebrovascular insufficiency or ischemic or hemorrhagic brain damage

Lewy Body

Characterized by a combination of cognitive impairment, psychosis, and features of parkinsons

symptoms of lewy body

Hallucinations, movement problems, altered gait, sleep disorders, dysregulation of autonomic body functions, changes in blood pressure or incontinence, and includes severe sensitivity to neuroleptics

neuroleptic malignant syndrome

severe fever and muscle rigidity, can lead to kidney failure

Frontotemporal dementia

Shrinkage of the frontal and temporal anterior lobes of the brain and is linked to several chromosomal mutations

symptoms of frontotemporal dementia

behavioural changes or challenges, inappropriate actions, lack of empathy, poor judgment, apathy, aphasia, poor hygiene, impulsiveness, movement disorders, and speech and language problems.

General Nursing Interventions: Dementia Care

create meaningful moments and activities, structure daily living to maximize remaining abilities, monitor general health and the impact of dementia alongside acute and chronic medical conditions while paying close attention to the person's experience of pain and mental health, create opportunities for social engagement, freedom of choice, self-expression, spirituality, and creativity, support advance care planning, and educate caregivers in problem-solving, long-range planning, emotional support, and accessing resources and respite.

Person-centered care

foster the client's abilities and sense of control, ensure their safety, maximize quality of life, prevent avoidable disability, support proper nutrition, create opportunities for meaningful interaction, and develop therapeutic relationships.

Sundowning

becoming restless and agitated in the late afternoon, evening, or night

7 A's

anosognosia, aphasia, amnesia, agnosia, apraxia, altered perception, and apathy.

Delirium

acute onset, fluctuating course, altered level of consciousness, inattention, and disorganized thinking

Delirium during hospitalization is associated with:

high morbidity and mortality, functional decline, increased postoperative complications, increased length of hospital stay and hospital readmissions, increased need for services after discharge, long-term cognitive decline, and high rates of institutionalization.

Hyperactive delirium

characterized by heightened arousal, restlessness, agitation, delusions, and/or aggressive behaviour

Hypoactive delirium

characterized by sleepiness, quieting of symptoms, and/or disinterested behaviour

Mixed delirium

characterized by alternating hyperactive and hypoactive states

Risk factors for Delirium

age 65 and older, use of medications such as sedatives, narcotics, or anticholinergics, or multiple medications, male gender, admission to the ICU and/or use of restraints, visual or hearing impairments, neurological diseases (e.g., stroke, encephalitis), reduced mobility and history of falls, infections, dehydration or malnutrition, severe illness, surgery, co-existing medical conditions, pain, emotional stress, and prolonged sleep deprivation.