Maturing Family Unit 3

medications affecting sleep

-SSRIs -Antihypertensives (clonidine, beta blockers, resperine, methyldopa) -Anticholinergics -Sympathomimetic amines -Diuretics -Opiates -Cough and cold medications -Thyroid preparations -phenytoin -cortisone -levodopa

Pressure Ulcers

70% occur in older adults a "localized injury" to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in combination with shear Affects health and quality of life In the United States, 11 billion dollars annually to treat Considered a geriatric syndrome Major cause of morbidity and mortality worldwide National Pressure Ulcer Advisory Panel has developed a registry to track the problem characteristics: Most frequently occur on the posterior aspects of the body, especially sacrum, heels, and greater trochanter (See Safety Alert, page 161) May also be seen on lateral knees and ankles, pinna of the ears, occiput, elbows, and scapulae 25-35% of PU are on the heels Persons with peripheral vascular disease at greatest risk for development of heel ulcers Risk factors: -Changes in skin -Comorbid illnesses -Nutrition status -Frailty -Surgical procedure (orthopedic/cardiac) -Cognitive deficits -Incontinence -Reduced mobility Consider intensity and duration of pressure and tissue tolerance Redness or blanching may NOT be the first sign in darker pigmented persons, but may look purplish in color or look like a bruise Prevention: Prevention is key A comprehensive program with multiple interventions appears to improve outcomes Significant interventions include addressing limited mobility, compromised skin integrity, and nutritional support A team approach is best when addressing this complex problem Key nursing sensitive quality indicator Can significantly impair recovery and rehabilitation and impact quality of life Increased risk of mortality High prevalence of health care litigation Centers for Medicare and Medicaid consider PU a preventable adverse event and do not reimburse treatment for PU acquired during admission Assessment: Thorough assessment of skin -Braden Scale Nutritional evaluation Laboratory studies Positioning Incontinence care Wound specialist nursing consult when indicated

Dry ARMD

90% of cases Rarely causes severe impairment Can lead to wet 3 stages Common early sign: Drusen bodies seen on fundoscopic examination

Dry Eye (keratoconjunctivitis sicca)

A common complaint rather than a disease Tear production diminishes with age More common in postmenopausal women Can be related to medications, Sjogren's syndrome Use artificial tears, consider Vitamin A deficiency

C

A mildly elevated core temperature, being cool and clammy, altered mental status, and thirst are signs of: A. heat fatigue. B. heat stroke. C. heat exhaustion. D. heat sensitivity.

Environmental Safety

A safe environment is one in which one is capable, with reasonable caution, of carrying out activities of daily living and instrumental activities of daily living (IADLs), as well as the activities that enrich one's life, without fear of attack, accident, or imposed interference Home Safety: Home safety assessments must be multifaceted and individualized to the areas of identified risks Particularly important for older adults at risk for falls

Conductive

Abnormalities of external and middle ear that reduce transmission of sound Causes include otosclerosis, infection, perforated eardrum, fluid in middle ear, tumor, cerumen accumulation Cerumen impaction occurs in 33% of nursing home residents

technology

Advancements in all types of technology hold promise for improving quality of life, decreasing the need for personal care, and enhancing independence and the ability to live safely at home and age in place Examples include: -telehealth -smart homes -robots

obstructive sleep apnea (OSA) (and sleep disordered breathing)

Affects approximately 25% of older adults with _________ being the most common form. Sleep disorders (Box 17-13) Untreated ______ is related to right heart failure, cardiac dysrhythmias, stroke, type 2 diabetes, and even death Age-related decline in the activity of the upper airway muscles, resulting in compromised pharyngeal patency, predisposes older adults to _______. Assessment: The individual may present with complaints of insomnia or daytime sleepiness, and assessment should include assessment of insomnia complaints If suspected, a referral for a sleep study should be made Recognition in older adults may be more difficult because they may not have a sleeping partner Interventions: Therapy depends on the severity and type of sleep apnea, as well as the presence of comorbid illness Continuous positive airway pressure is recommended as initial therapy Teaching should include the effects of untreated _____ and emphasize the need for treatment

Glaucoma

Affects over 2.3 million persons over the age of 40 and almost half don't know they have it African Americans at greater risk for developing it at an early age Primary open angle _______ is most common and is the second leading cause of legal blindness in the United States Other types include congenital, low and normal tension, secondary, and acute angle closure Screening and Treatment: -Adults over the age of 65 or those at risk should have an annual eye examination with dilation -Treated with oral or topical eye drops to decrease intraorifice pressure (IOP) (beta-blockers first line of therapy), trabeculoplasty, and filtration surgery

Wet ARMD

Also called neovascular Abnormal blood vessels grow under the macula, causing its displacement Affects central vision Progression can be rapid with resultant blindness within 2 years

low-vision optical devices

An array of _______ assistive devices are available Persons with severe visual impairment may qualify for disability, financial, and social service assistance through government and private programs

continence program (in nursing homes)

Are required by Centers for Medicare and Medicaid regulations Monitoring and documentation of continence status related to implemented continence care is a quality indicator in nursing homes Newly admitted incontinent nursing home residents should receive a 3-5 day trial of prompted voiding (PV) or other toileting program

transportation safety

Available transportation is a critical link in the ability of older adults to remain independent and functional A "crisis in mobility" exists for many older people because of lack of an automobile, inability to drive, limited access to public transportation, health factors, geographical location, and economic considerations Adequate, affordable, and convenient transportation services are essential to health and quality of life, as well as the ability to age in place Driving: Driving is one of the IADLs for most elders because it is essential to obtaining necessary resources Driving is a highly complex activity that requires visual, motor, and cognitive skills As individuals age, the risk for impairment that affects driving skills increases due to changes related to aging, as well as disease-related changes Driving Safety: When compared with younger age groups, older people have more accidents per mile driven and have a ninefold increased risk of traffic fatality The leading cause of injury-related deaths among drivers 65-74 years of age is a motor vehicle accident and, if over 75 years, the second leading cause of death, after falls Silver alert system Driving and Dementia: Driving has been identified as one of the top 10 tough ethical issues associated with dementia Evidence of some studies of motor vehicle crashes suggests that drivers with dementia have at least a twofold risk of crashes compared to those without cognitive impairment Legal regulations regarding driver's license renewal in older drivers and the responsibility of medical practitioners to identify unsafe drivers vary from state to state and country to country Driver Cessation Giving up driving is a major loss for an older person both in terms of independence and pleasure, as well as feelings of competence and self-worth Planning for driver cessation should occur for all older adults before their mobility situations become urgent Assessments of functional capacities often neglect driving ability The mnemonic SAFE DRIVE addresses key components in screening older drivers

seborrheic keratosis

Benign growth Mainly see on trunk, face, scalp, and neck Waxy, raised, stuck-on appearance Flesh colored or pigmented, various sizes

Visual Impairment

Blindness and _______ are major causes of disability in older adults As the population ages, rates of blindness and ______ in disadvantaged and minority populations will increase in prevalence In 2013, the World Health Organization approved the "Global Action Plan for Prevention of Avoidable Blindness and Visual Impairment" Consequences: -Associated with cognitive and functional decline, decreased quality of life, and depression -Associated with increased risk for injury and falls -"Snowball" effect, impacting families, caregivers, and society at large Prevention: -Only about half of persons with diabetes know that their eyes could be affected -Have yearly dilated eye examination -Get routine eye examinations

bowel elimination

Bowel function is only slightly altered by physiological changes of aging, but can be a source of concern and potentially serious Normal elimination should be easy passage of feces, without undue straining or a feeling of incomplete evacuation or defecation small intestine: -villi become broader, shorter, and less functional -blood flow decreases -proteins, fats, mineral (including calcium), vitamins (esp. B12), and carbs (esp. lactose) are absorbed more slowly and in lesser amounts Large intestine: -slowed peristalsis -blunted response to rectal filling - increased collagen deposition leading to dysmotility -fibro-fatty degeneration and increased thickness of the internal anal sphincter Assessment: It is important to obtain a bowel history including usual patterns, frequency, size, consistency, any changes, and occurrence of straining and hard stools The precipitants and causes of constipation must be included in the evaluation Box 16-16 provides a resource for a bowel diary and the Bristol Stool Form Scale Interventions: -Nonpharmacological interventions -Physical activity -Positioning -Toileting regimen -Pharmacological interventions (Box 16-2) -Enemas (Safety Alert page 216) -Alternative treatments (Box 16-18)

Elimination

Can be severe enough to interfere with ability to continue independent living and threaten body's capacity to function and survive Can threaten a person's independence and well-being Nurses are in a key position to implement evidence-based assessment and interventions to enhance continence and improve function, independence, and quality of life Changes in the Renal and Urological System: -Age-related loss of nephrons, kidney mass, and ability to concentrate urine generally lead to little change in the body's ability to maintain adequate fluid homeostasis -Renal disease or urinary tract obstruction can amplify age-related decline in function -Urinary incontinence (UI) and frequency should never be considered a normal part of aging

skin cancer

Cancer of the skin is the most common cancer Major public health problem on the rise One in 5 Americans will develop it in the course of a lifetime Caucasian populations are at a higher risk All skin types should minimize sun exposure Use ABCDE approach to assess for danger signs

Candidiasis

Caused by fungus Candida albicans found on the skin Risk factors for infection: obesity, malnourishment, antibiotic or steroid use, immunocompromised, chemotherapy, and diabetes Found in warm, moist areas of skin, like skinfolds, axilla, groin Commonly called "thrush" when inside the mouth

scabies

Causes intense itching Caused by tiny mite, Sarcoptes scabiei Contagious, easily transmitted through close physical contact; intimate or casual ______ with thick crust contain large number of mites and eggs May be transmitted on clothing, linen, furniture Diagnosed visually or via skin scraping Treated with prescribed lotions and creams; clothes and linens need to be washed in hot, soapy water and dried with high heat; rooms cleaned and vacuumed

Dysphagia

Common problem of older adults As many as 60% of nursing home residents demonstrate clinical evidence of dysphagia A serious problem with negative sequelae including weight loss, malnutrition, dehydration, aspiration pneumonia, and even death Risk factors: -Cerebrovascular accident -Parkinson's disease -Neuromuscular disorders: amyotropic lateral sclerosis, multiple sclerosis, myasthenia gravis, dystonia -Dementia -Head and neck cancer -Traumatic brain injury -Aspiration pneumonia -Inadequate feeding technique -Poor dentition Signs and Symptoms: *Best Practices: Aspiration Prevention -Difficult, labored swallowing -Drooling -Copious oral secretions -Coughing, choking at meals -Holding or pocketing of food in the mouth -Difficulty chewing -Nasal voice or hoarseness -Wet or gurgling voice -Excessive throat clearing -Food or liquid leaking from nose -Prolonged eating time -Discomfort during swallowing -Sensation of something stuck in throat during swallowing

Dehydration

Complex problem that results in reduction of total body water Often related to changes of aging in older adults Considered a geriatric syndrome *Significant issues: thromboembolic complications, kidney stones, constipation, falls, medication toxicity, renal failure, seizure, electrolyte imbalance, hyperthermia, and delayed wound healing Majority of older people develop _______ from increase fluid losses combined with decreased fluid intake, related to decreased thirst *Risk factors include: emotional illness, surgery, trauma, higher physiological demands (see Box 15-3) Signs and Symptoms: -Often atypical in the older adult -Skin turgor is not a reliable indicator in older adults -Look for dry mucous membranes in mouth and nose, furrows on the tongue, orthostasis, speech incoherence, rapid pulse, decreased urine output, extremity weakness, dry axilla, and sunken eyes. Laboratory test and urine: Labs: serum sodium, serum and urine osmolarity, and specific gravity Most cases of dehydration have an elevated blood urea nitrogen (BUN); however, there are many other causes for elevation of BUN/creatinine ratio Urine color chart may be helpful in monitoring hydration status Better indicator when monitored over a couple of days Interventions: -Based on comprehensive assessment, risk identification, and hydration management -Monitor closely and implementation of intake and output is essential -Oral hydration is the first treatment approach -Water is the best fluid to offer

feeding tubes

Comprehensive assessment of all factors influencing dysphagia prior to consideration of feeding tubes do not prevent aspiration or risk of aspiration Use of PEG (percutaneous endoscopic gastrostomy) feeding tubes has increased dramatically in past few years not associated with -improved survival. -reduced incidence of pneumonia. -improved function. -fewer PU. are associated with complications including: -cellulitis. -diarrhea. -aspiration pneumonia. -metabolic problems. Interfere with basic psychological, biological, and cultural needs associated with eating Decisions about ______ are complex and should involve patient's advance directives and family and include full disclosure of risks and benefits Up to 50% of patients with PEG placement die within 6 months of insertion Assessment of all factors for poor nutritional uptake including meal environment, feeding techniques, food preferences, medications, and depression should be investigated before decision on enteral feeding

Ocular Changes

Cornea becomes flatter, less smooth, thicker, and loses luster Increased astigmatism Chambers that control the movement of aqueous fluid decrease in size and volume capacity, leading to development of glaucoma Iris is slower to respond to changes from light to dark Glare is a major problem Decreased ability of the lens to accommodate Development of cataracts from ultraviolet exposure

Constipation

Defined as the reduction in the frequency of stool or difficulty in formation or passage of stool The Rome III Criteria outlines operational definitions of constipation and guide to diagnosis (Box 16-14) Associated with impaired quality of life, significant health care costs, large economic burden, and can lead to serious consequences It is a symptom, not a disease

oral care

Dental health increasingly neglected with advanced age, debilitation, and limited mobility Poor oral health associated with dehydration, malnutrition, and other systemic diseases Common problems: -Xerostomia (mouth dryness) and hyposalivation -30% of older adults affected -Affects eating, swallowing, speaking -More than 500 medications cause hyposalivation -Treatment: review medications, good oral hygiene, adequate water, avoid alcohol and caffeine, over-the-counter oral saliva substitutes Assessment: -Physical examination of oral cavity and oral health -Federal regulations mandate annual examination for LTC residents -Oral health instrument: The Kayser-Jones Brief Oral Health Status Examination (BOHSE) Interventions: -Promote oral health through teaching persons and caregivers recommended interventions, screening for oral disease, making dental referrals -Provide supervision and evaluation of oral care in hospitals and LTC facilities

rehydration

Depends on severity and type of dehydration Intravenous -Replace 50% of loss within first 12 hours or sufficient quantity to relieve tachycardia and hypotension Hypodermoclysis -Infusion of isotonic fluids into the subcutaneous space -Not for severe dehydration

Intraocular Changes

Deterioration of vitreous humor may lead to development of "floaters" (lines, webs, spots, dots) Retinal changes affect color, with red, orange, and yellow seen more easily Color clarity diminishes by 59% in the eighth decade, secondary to yellowing of the lens Drusen spots may appear on the macula

postfall assessment

Determination of why a fall occurred is vital and provides information on underlying fall etiologies so that appropriate plans of care can be instituted The purpose of the assessment is to identify the clinical status of the person, verify and treat injuries, identify underlying causes, and assist with risk reduction interventions Components of an assessment include fall-focused history, fall circumstances, medical problems, medication review, mobility assessment, vision and hearing assessment, neurological examination, and cardiovascular examination

elder-friendly communities

Developing _______ and increasing opportunities to age in place can lead to enhanced health and well-being Components: -Addresses basic needs -Optimizes physical health and well-being -Maximizes independence for frail and disabled -Provides social and civic engagement Aging in Community Models: -Naturally occurring retirement communities are neighborhoods or buildings in which a large segment of the residents are older -Provide a range of health and social services for residents, as well as individual assessments of risk, coordination of nonprofessional services, and referrals and follow-up -Examples: the village model, cohousing communities, and shared housing

acute angle closure (glaucoma)

Emergency Angle of iris obstructs flow of aqueous humor May be related to infection or trauma Intraocular pressure rises rapidly Eye is red and painful, severe H/A, N/V Avoid anticholinergics

Detached Retina

Emergency medical treatment required to save vision Actual areas of the retina are torn that lead to retinal detachment May have gradual increase in floaters and/or light flashes in the eye Repair requires surgery Early intervention improves vision results

Feeding Assistance

Estimated that 50% of all residents unable to eat independently Inadequate staffing is associated with poor nutrition and hydration The Centers for Medicare and Medicaid Services implemented a rule that allows feeding assistance, with 8 hours of approved training

xerosis

Extremely dry, cracked, and itchy skin Most common skin problem associated with aging Caused by decrease in epidermal filaggrin, which is a protein required for binding of keratin into macrofibrils Seen primarily on the extremities, mostly legs, but may affect trunk and face

extraocular changes

Eyelids lose elasticity contributing to drooping entropin ectropion xerophthalmia

falls assessment

Fall risk assessment should be an integral part of primary health care for the older adult The intensity of the assessment will vary with the target population -Low-risk community-dwelling individuals -Those who report a single fall -High-risk populations Hospital/Long-Term Care: -Individuals admitted to acute care or LTC should have an initial assessment on admission, after any change in condition, and at regular intervals during their stay -Assessment is an ongoing process that includes multiple and continual types of assessment, reassessment, and evaluation following a fall or intervention to reduce risk Instruments: -commonly included in fall prevention interventions -The National Center for Patient Safety recommends the Morse Fall Scale, except for LTC -The Hartford Foundation for Geriatric Nursing recommends the Hendrich II Fall Risk Model, which has been validated with skilled nursing and rehabilitation populations

fall interventions

Fall risk reduction programs Environmental modifications Assistive devices (Box 19-17) Safe patient handling (Box 19-18) Wheelchairs Osteoporosis treatment/vitamin D supplements Hip protectors Alarm motion sensors Restraints and side rails: A physical restraint is defined as any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a person to move his or her arms, legs, body, or head freely A chemical restraint is when a drug or medication is used as a restriction to manage the person's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the person's condition Consequences of Restraints -Physical restraints may exacerbate many of the problems they are used for and can cause serious injury and death, as well as emotional and physical problems -The most common mechanism of restraint-related death is asphyxiation -Use of restraints is a great source of physical and psychological distress to older adults and may intensify agitation and contribute to depression Side Rails: -Side rails are now defined as restraints or restrictive devices when used to impede a person's ability to voluntarily get out of bed and the person cannot lower them by him or herself -No evidence that side rails decrease the risk or rate of fall occurrence Restraint-Free Care Is now a standard of practice and an indicator of quality care in all health care settings, although the transition to the standard of care is still in progress

Dietary Recommendations

Fats: 20-35% of total calories, limit saturated fat and trans fatty acids Protein: increase to 20-25% total calories for older adult who tends to experience protein deficiency when ill; minimizes frailty Fiber: 25 grams fiber recommended daily (Box 14-5) Vitamins and minerals: consumption of five servings of fruits/vegetables provides adequate A,C,E, and potassium; changes of aging contribute to decreased absorption of B12

purpura

Fragility of dermal capillaries secondary to dermal thinning causing blood vessels to rupture Extravasation of blood into surrounding tissue is called _______. Commonly seen on dorsal forearm and hands Increases with age Persons on blood thinners are more susceptible

D

How much time should be devoted to moderate activity in order to improve health? A. 30 minutes three times a week B. 60 minutes daily C. 45 minutes two times a week D. 30 minutes daily 5 times a week

B

Hypothermia is defined as having a core body temperature ( F) of less than: A. 97.5 B. 95.0 C. 93.2 D. 90.5

D

In order to effectively incorporate physical activity into lifestyle, a person: A. doesn't need expensive gym equipment. B. incorporates muscle strengthening exercises without weight bearing. C. considers group exercise for its social and emotional health benefits. D. all of the above.

Cochlear Implants

Increased use for sensorineural hearing loss where hearing aids aren't effective Bypasses damaged portions of the ear and directly stimulates auditory nerve Two parts: one piece surgically implanted under the skin and external portion that sits behind the ear Surgery destroys residual hearing Avoid magnetic resonance imaging

Urinary Catheters

Intermittent catheterization -Usually used for weak detrusor muscle, blockage of urethra, benign prostatic hyperplasia, reflux incontinence Indwelling catheter -Long-term use increases risk of recurrent UTIs leading to urosepsis, urethral damage in men, urethritis, or fistula formation -Most frequent health care-associated infection in the United States and not reimbursed by Medicare External catheter -"Condom catheters" used for male patients

approaches to enhancing intake (LTC)

Interventions: -Restorative dining rooms -Consideration of ethnic food choices -Easy access to refreshment stations with juices, water, healthy snacks, and finger foods -Family involvement when possible Other considerations: restrictive diets and caloric supplements, pharmacological therapy, patient education, and dysphagia

fecal incontinence

Involuntary loss of liquid or solid stool that is a social and hygienic problem Prevalence: -Community: 2-17% -Nursing homes: 50-65% -Hospitalized: 33% Higher prevalence rates are found in persons with diabetes, irritable bowel syndrome, and stroke Also associated with UI Devastating social ramifications for persons and families Assessment: The term accidental bowel leakage is preferred over _____. Assessment should include complete client history as in UI and investigation into stool consistency and frequency, use of laxatives or enemas, surgical and obstetric history, medications, effects of incontinence on quality of life, focused physical examination with attention to the gastrointestinal system, and a bowel record Interventions: -Environmental manipulations (accessible toilet) -Diet alterations -Habit-training schedule -Pelvic floor muscle exercises -Improving transfer and ambulation ability -Sphincter training exercises -Biofeedback -Medications -Surgical intervention

Pruritis

Itchy skin (not a disease, but a symptom) Can cause skin injury secondary to scratching Aggravated by perfumed detergents, fabric softeners, heat, sweating, restrictive clothing, fatigue, exercise, and medications May result from systemic disease such as chronic renal failure, biliary, or hepatic disease Failure to control itching increases risk for eczema, excoriations, cracks, infection

Oral Hygiene in Hospitals (and LTC)

Lack of attention to oral hygiene contributes to poor nutrition and negative outcomes Cleaning teeth with a toothbrush after meals lowers risk of aspiration pneumonia Crucial in prevention ventilator-associated pneumonia LTC residents vulnerable secondary to cognitive impairment and dependency on staff to provide good oral care

Risks and Vulnerability

Living alone, sensory, mobility, memory impairments, and loneliness make elders more susceptible to crime Property crime is the most common crime against persons 65 years and older Fraudulent Schemes Against Elders: -Fraud against elders ranges from solicitations from seemingly worthwhile charities to requests for a cash deposit to win a prize -Medical fraud is another serious type of fraud that effects older citizens on a national scale Fire Safety: Fire-related mortality rates are three times higher in people older than 80 years than in the rest of the population Most fires occur at home during the night, and deaths are attributed to smoke injury more often than burns Environmental temperature extremes impose a serious risk to older persons with declining physical health Preventative measures require attentiveness to impending climate changes, as well as protective alternatives Temperature Monitoring in Older Adults: -Up to one-third of older people with acute infections may present without a robust febrile response, leading to delays in diagnosis and appropriate treatment, as well as increased morbidity and mortality -A temperature of 98.6 F may indicate fever in frail older people Recognition of clinical signs and severity of hyperthermia and hypothermia is an important nursing responsibility Closely monitor body temperature and pay particular attention to lower or higher than normal readings compared to baseline Nurses must advocate for resources in the community to ensure appropriate temperature in homes of older people and surveillance when temperature changes

Indoor Tanning

Melanoma is most common cancer in people less than 30 years Indoor tanning increases risk of melanoma by 75% when started before age 35 2.5 times more likely to develop squamous cell 1.5 times more likely to develop basal cell Goal of Healthy People 2020 is to reduce the use of devices

Fecal impaction

More commonly seen in institutionalized older adults who require narcotic medications for chronic pain and is reported in 40% of older adults admitted to the hospital Unrecognized, unattended, or neglected constipation eventually leads to fecal impaction Removal is at times worse than the misery of the condition Management requires digital removal of the hard, compacted stool from the rectum with lubrication containing lidocaine jelly

UTI

Most common cause of bacterial sepsis in older adults and 10 times more common in women Assessment and appropriate treatment in older people, particularly in the nursing home, is complex Persons may be cognitively impaired or do not present with classic symptoms The diagnosis of symptomatic ____ is based on clinical features and laboratory evidence

Age-Related Macular Degeneration

Most common cause of new visual impairment among persons greater than 50 years and increases with age Progressive loss of central vision Caused by systemic changes in circulation, accumulation of cellular waste, tissue atrophy, and growth of abnormal vessels in choroid layer beneath the retina Fibrous scarring affects nourishment of photoreceptor cells -Wet -Dry Screening and Treatment -Early diagnosis is key -Amsler grid to determine clarity of vision helps identify central vision problems -Treatment: photodynamic therapy, laser photocoagulation, and anti-vascular endothelial growth factor (VEGF) therapy

basal cell (skin cancer)

Most common malignant skin cancer Mainly in older persons Slow growing and metastasis rare Triggered by extensive sun exposure, burns, chronic irritation, or ulceration Early detection and treatment minimizes damage

insomnia

Most common sleep disorder worldwide Interferes with sleep quality and quantity and is associated with subjective complaints of sleep characterized by: -difficulty initiating sleep. -difficulty maintaining sleep. -premature morning awakening. -nonrestorative sleep. Alzheimer's disease: -About half of individuals with dementia experience sleep dysregulation, which may be associated with agitation, wandering, comorbid illness, primary sleep disorders, or medications used to treat the dementia -Caregivers also experience poor sleep quality, leading to stress and health problems -Behavior techniques to enhance sleep for those with AD: sleep hygiene education, daily walking, and increased light exposure

Diabetic Retinopathy

Most diabetic patients will develop ______ within 20 years of diagnosis Leading cause of new blindness between ages 20 and 74 Four stages: -Mild nonproliferative -Moderate nonproliferative -Severe nonproliferative -Proliferative Screening and Treatment: -Early detection is essential -Annual fundoscopic dilated eye examination -Fundoscopic evaluation includes flame shape hemorrhages, cotton wool spots, hard exudates dilated capillaries, and microaneurysms -Maintain strict control of blood sugar, cholesterol, and blood pressure

95%

Nearly _____ of those over 65 years of age wear glasses

melanoma

Neoplasm of the melanocytes Accounts for less than 2% of all skin cancers Highest incidence in Caucasians Multicolored, raised, asymmetrical, irregular borders More common in men than women Risk factors: more than 50 moles, sun sensitivity, history excessive sun exposure, severe sunburns, tanning beds

thermoregulation

Neurosensory changes in thermoregulation delay or diminish the individual's awareness of temperature changes and may impair behavioral and thermoregulatory response to dangerously high or low temperatures Drugs can affect ________. Economic, behavioral, and environmental factors may combine to create a dangerous thermal environment affecting the older person

Sleep

Occupies a third of our lives and is a vital function that affects cognition and performance is a barometer of health and sleep assessment and interventions for sleep concerns should receive as much attention as other vital signs Insufficient sleep is a public health epidemic and the Centers for Disease Control and Prevention has called for continued public health surveillance of sleep quality, duration, behaviors, and disorders to monitor for sleep difficulties and their health impact Aging: The body progresses through five stages of normal sleep pattern consisting of rapid eye movement (REM) sleep and non-rapid eye movement sleep (Box 17-3) REM sleep declines with aging and is a "critical state for sleeping elders" when the brain replenishes neurotransmitters Age-related sleep changes (Box 17-4) The most notable changes are an increase in number of nighttime awakenings and lower sleep efficiency Assessment: Nurses are in an excellent position to assess sleep and suggest interventions to improve the quality of the older person's sleep Assessment for sleep disorders and contributing factors to poor sleep (pain, chronic illness, medications, alcohol use, depression, anxiety) are important Sleep diary (Box 17-8) Interventions: Nonpharmacological treatment -Directed at identifiable cause -Considered first-line treatment for insomnia -Nonpharmacologic interventions (Box 17-10) --Sleep hygiene --Relaxation techniques --Sleep restriction measures --Stimulus control --Circadian interventions Sleep in hospitals and nursing homes: -22-61% of hospitalized patients experience impaired sleep -Suggestions to promote sleep in the hospital or nursing home (Box 17-11) -Efforts to allow sufficient time for a person to complete a full sleep cycle of 90 minutes are important and can have a positive influence on sleep effectiveness Pharmacological treatment: -Use of over-the-counter sleep aids and prescription sedatives and hypnotic medications is increasing in the United States -Benzodiazepines represent 17-23% of drugs prescribed to older adults and is one of the most abused drugs, along with opiates, in the older population -Benzodiazepines or other sedative hypnotics should not be used in older adults as a first choice of treatment for insomnia -Health education on sleeping medications (Box 17-12)

oral cancers

Occur more frequently later in life Occur more frequently in men than women Early detection essential as 60% of cases aren't diagnosed until Stage 4 Risk factors (Box 15-10) -Tobacco use -Alcohol use -HPV (human papillomavirus) infection -Genetic susceptibility

REM sleep behavior disorder

Occurs around age 60 years Loss of normal voluntary muscle atonia during REM sleep, associated with complex behavior while dreaming

skin tears

Occurs because skin is thin and fragile Painful, acute, accidental in nature Categorized according to the Payne-Martin classification system Management: proper assessment, control of bleeding, cleanse with nontoxic solution, appropriate dressing, management of exudate, and prevention of infection

skin

Often overlooked because focus is on acute problems or disease Can affect health and compromise quality of life Many age-related changes are visible Due to aging, genetics, environment functions: -Protect underlying structures -Regulate body temperature -Sensory input -Stores fat -Metabolism of salt and water -Gas exchange -Production of vitamin D

natural disasters

Older people are at a great risk during and after disasters and have the highest casualty rate during disaster events when compared to all other groups Older adults at most risk include those: -that depend on others for daily functioning. -with limited mobility. -socially isolated, cognitively impaired, or institutionalized. Nursing home residents are particularly vulnerable due to frailty, and nursing homes need to be prepared for disasters Gerontological nurses must be knowledgeable about disaster preparedness and assist in the development of plans to address the unique needs of older adults, as well as educate fellow professionals and community agencies about the special needs of older adults.

B

One of the most common visual changes associated with aging is: A. macular degeneration. B. presbyopia. C. glaucoma. D. cataract

falls

One of the most important geriatric syndromes and the leading cause of morbidity and mortality for people older than 65 years of age Leading cause of both fatal and nonfatal injuries Two-thirds of falls may be preventable Falls are a significant public health problem A key nursing quality indicator Education on falls and fall risk reduction is an important consideration in the Quality and Safety Education for Nurses safety competency Consequences: Hip Fractures -95% of hip fractures are caused by falls -Hip fractures are associated with considerable morbidity and mortality Traumatic Brain Injury (TBI) -Persons over the age of 75 years have the highest rates of TBI-related hospitalization and death -Falls are the leading cause of TBI for older adults -Signs and symptoms of TBI (Box 19-5) Fallophobia -Fear of falling is an important predictor of general functional decline and risk factor for future falls Risk Factors: -are a symptom of a problem and are rarely benign in older people -The etiology of falls is multifactorial -A history of falls is an important risk factor and individuals who have fallen have three times the risk of falling again -drugs -environmental hazards -weakness -gait/balance impairment -ADL impairment -Sensory deficit -age-related frailty -vertigo -cognitive impairment -medical illness Precipitation causes: -trip/slip -syncope -dizziness -drop attack Gait Disturbances: -Affect 20-50% of people older than 65 years -Are not a normal consequence of aging alone, but most likely indicative of underlying pathological condition Foot Deformities -Falls were reduced 36% in those with disabling foot pain who received enhanced podiatry care -Approximately 90% of adults over age 65 have some form of altered foot integrity -Foot health and function may reflect systemic disease or give early clues to physical illness Nursing care should be directed toward optimal comfort and function, removing possible mechanical irritants, and decreasing likelihood of infection The nurse has the important function of assessing the feet for clues of functional ability and their owner's well-being Cognitive Impairment -Older adults with cognitive impairment, such as dementia or delirium, are at increased risk for falls Vision and Hearing -Poor visual acuity, reduced contrast sensitivity, decreased visual field, cataracts, and use of nonmiotic glaucoma medications have all been associated with falls Medications -Medications implicated in fall risk include those that cause drowsiness, mental confusion, problems with balance or loss of urinary control, and sudden drops in blood pressure when standing

Cataracts

Opacity of the lens causing the lens to lose transparency and scatter light Often caused by oxidative damage Cardinal sign is appearance of halos around objects as light is diffused Treatment: -Requires surgery under local anesthesia -95% return to excellent vision -Education regarding vision and adaptation to light changes -Post-surgery avoid heavy lifting, straining, bending at the waist -Fall prevention

vision problems s/s

Pain in eyes Difficulty seeing in the dark Double vision/distorted vision Migraine headaches with blurred vision Flashes of light Halos surrounding lights Difficulty driving at night Falls or injuries

dentures

Patient and/or caregiver education of proper cleaning techniques Damaged and ill-fitting dentures are a common problem Only 13% of persons with ______ get an annual dental examination

Hearing Aids

Personal amplifying system Numerous types: digital, analog, vary in size, appearance, effectiveness Type of device depends on type of hearing impairment and what the person can afford Not usually covered by insurance or Medicare

CAUTI (catheter associated urinary tract infection)

Persons who develop UTI with an indwelling catheter in place or within 48 hours of removal Most common hospital-acquired infection worldwide Implementation of evidence-based guidelines, catheter reminders, stop orders, nurse-initiated removal, and urinary catheter bundle can decrease _____ in acute care

actinic keratosis

Precancerous Related to exposure to UV light Risk: increased age, fair complexion Rough scaly sandpaper patches Pink to reddish brown with erythematous base

FFC (function-focused care)

Previously known as restorative care Comprehensive, systems-level approach that prioritizes the preservation and restoration of functional capacity A philosophy of care in which nurses acknowledge older adults' physical activities and cognitive capabilities with regard to function and integrate functional and physical activities into all care interactions

hypothermia

Produced by exposure to a cold environment and defined as a core temperature of less than 35°C (95°F) is a medical emergency requiring comprehensive assessment of neurological activity, oxygenation, renal function, and fluid and electrolyte balance

primary open angle (glaucoma)

Progressive, asymptomatic with visual field loss May complain of headache, poor vision in dim lighting, tired eyes Increased intraocular pressure damages optic nerve Vision loss can be prevented if detected early

physical activity

Regular _________ throughout life is essential for healthy aging Enhances health and functional status while decreasing the number of chronic illnesses and functional limitations A protective factor for depression Only 40% of men and 31% of women aged 65-74 years in the United States exercise regularly The World Health Organization calls increasing physical activity a societal problem that demands a population-based, multisectoral, multidisciplinary, and culturally relevant approach Even a small amount of physical activity, at least 30 minutes of moderate activity several days a week, can improve health Assessment: Assessment of function and mobility are components of a health assessment for older adults Exercise counseling should be provided as part of the assessment Frail individuals will need more comprehensive assessment to adapt exercise recommendations to their abilities to ensure benefit without compromising safety Screening: The Exercise and Screening for You tool can be used to determine a safe exercise program for older adults on the basis of underlying physical conditions (resource listed in Box 18-2) The Hendrich II Fall Risk Model includes the Get-Up-and-Go test, which can be used to assess mobility, gait, and gait speed Interventions: -The nurse should be knowledgeable about recommended physical activity guidelines, educate individuals about the importance of exercise and physical activity, and provide suggestions on ways to incorporate exercise into daily routines -Older people are less likely to receive exercise counseling from their primary care provider than younger individuals -Nurses can design and lead exercise and physical activity programs Incorporation: -Doesn't require expensive equipment -Benefits of group exercise in terms of social and emotional health have been reported -Muscle strengthening exercises without weight bearing provide joint stability -Swimming is a low-risk activity that provides aerobic benefit, and water-based exercises are particularly beneficial for individuals with arthritis or other mobility limitations Special Considerations: The benefits of physical activity extend to the more physically frail older adult, those who are nonambulatory, experience cognitive impairment, and those residing in assisted living facilities or skilled nursing facilities Research suggests that older adults with cognitive impairment who participate in exercise programs may improve strength and endurance, cognitive function, and ability to perform activities of daily living Maintaining Function in acute care setting: There is a growing awareness of the need to focus on hospitalized older adults Hospitalization is associated with significantly greater loss of total, lean, and fat mass strength in older persons A baseline assessment of functional ability is important and can assist in setting appropriate goals for hospitalized individuals The plan of care should include interventions to maintain or improve function for all acutely ill older adults

circadian rhythm sleep disorder

Relatively normal sleep occurs at abnormal times

Malnutrition (Undernutrition)

Rising incidence in acute care, long-term care (LTC), and in the community Institutionalized older adults at high risk for malnutrition due to chronic disease and functional impairments Increased risk of infection, pressure ulcers (PUs), anemia, hip fractures, hypotension, impaired cognition, and increased morbidity and mortality Can be related to inadequate consumption of micro and macro nutrients, or consequence of inflammation Comprehensive screening and assessment is critical to identify older adults at risk

E

Risk factors for falls include: A. OH. B. cognitive impairment. C. vision and hearing problems. D. foot deformities. E. all of the above.

squamous cell (skin cancer)

Second most common Aggressive and high incidence of metastasis Major risk factors are sun exposure, fair skin, immunosuppression Slightly different clinical presentations and may be overlooked Treatment depends on size, histology, and patient preference

Presbycusis

Sensorineural (age related): most common form of hearing loss, worsens with age, first sign is difficulty hearing in noisy environments, affects high frequency

Noise induced

Sensorineural second most common cause, mechanical injury to the sensory hair cells of cochlea, continuous noise exposure, expected to rise, consider better ear protection devices

B

Signs and symptoms of dehydration in an older adult include all of the following except: A. dry mucous membranes in mouth and nose. B. decreased skin turgor. C. dry axilla. D. speech incoherence.

SCALE (skin changes at life's end)

Skin failure is defined as "an event in which the skin and underlying tissue die due to hypoperfusion that occurs with severe dysfunction or failure of other organs" Occurs during the last days or weeks of life Unavoidable part of dying and occur even if evidence-based strategies are employed Appropriate interventions are considered based on the 5 P's (Box 13-9)

Orthostatic and Postprandial Hypotension

The detection is of clinical importance to falls prevention since it is treatable coupled with dizziness has been found to be predictive of falls ________ hypotension occurs after the ingestion of a carbohydrate meal and may be related to release of vasodilatory peptide

Biorhythm

The most important ________ is the circadian sleep-wake rhythm As people age, the natural circadian rhythm may become less responsive to external stimuli, such as changes in light during the course of the day Endogenous changes in the production of melatonin are diminished, resulting in less sleep efficacy

Nutrition

The quality and quantity of diet are important factors in preventing, delaying onset, and managing chronic illnesses associated with aging Diet can affect longevity, and when combined with lifestyle changes, reduces disease risk A lifetime of good nutrition would positively improve 9 out 10 of the leading causes of death Age-related changes affect the gastrointestinal (GI) system (Box 14-1), but are not the primary cause of inadequate nutrition in older persons Factors impacting nutritional needs are most likely related to chronic disease, lifelong eating habits, ethnicity, socialization, income, transportation, housing mood, food knowledge, functional impairments, health, and dentition Age-Related Requirements -Based on 2010 Dietary Guidelines for Americans Choose My Plate is a guide that provides a visual depiction of daily food intake -Older adults generally need less calories because activity decreases and metabolic rates slow down -Still require the same or higher amounts of nutrients Factors affecting fulfillment of needs: -Age-related changes in taste and smell -Lifelong eating habits Box 14-9 -Socialization -Chronic diseases and conditions -GI disorders (prevent and treat) --Gastroesophageal reflux disease (GERD) (Box 14-11) --Diverticular disease Box 14-10 -Socioeconomic deprivation -Transportation Implications: Nutrition screening and assessment (Box 14-12) -Several screening tools available Figure 14-3 and Figure 14-4 -Minimum Data Set—includes risk factors and triggers for further evaluation -Interview and physical examination -Anthropometrical measurements -Weight/height considerations -Biochemical analysis/measures of visceral protein Interventions: Formulated around specific problems Nurses hold a pivotal role in ensuring adequate nutrition to promote healthy aging Collaboration with interprofessional team Considerations: modification of environment, supervision, feeding techniques that enhance intake and preserve dignity and independence Evaluate the outcome

E

The use of restraints can lead to which of the following? A. Death B. Depression C. Exacerbation of agitation D. Asphyxiation E. All of the above

DME (diabetic macular exam)

Thickening of the center of the retina Most common cause of visual loss due to diabetes and leading cause of legal blindness Treat with cortisone drugs and laser therapy Retinal vessels become leaky and fluid accumulates within the macula Annual dilated retinal examination

hearing impairment

Third most prevalent chronic condition and the foremost communicative disorder Under recognized public health issue Men are more likely than women 63% of persons over the age of 70 are affected Factors affecting hearing impairment are complex and include age-related changes, genetics, lifestyle, and environmental factors Consequences: -Diminishes quality of life -Decline in function -Increased hospitalizations -Miscommunication -Depression -Falls -Loss of self-esteem -Safety risks -Cognitive decline -Increases feelings of isolation -May be diagnosed with dementia inappropriately interventions: -Personal listening systems -Adjunct to hearing aids or used in place of -Enhance face-to-face communication -Text messaging devices -Closed-caption -Special service dogs -Use of computers and email -Pocket-sized amplifiers Screening for hearing impairment is essential primary care for older adults Assessment includes focused history and physical examination and screening assessment Self-assessment instruments may be helpful (Box 12-5) May require referral to an audiologist Removal of cerumen impaction

tube feedings and oral hygiene

Tube feedings are associated with significant pathological colonization in the mouth Provide oral care every 4 hours for persons with gastrostomy tubes and brush teeth after each feeding Only toothbrushes assist in the removal of plaque; use foam swabs to clean mouth of endentulous

A

Untreated OSA can lead to all of the following, EXCEPT: A. left heart failure. B, cardiac dysrhythmias. C. stroke. D. type 2 diabetes.

Herpes Zoster (Shingles)

Viral infection caused by reactivation of the varicella-zoster (chicken pox) virus Preceded by itching, tingling, rash along the dermatome prior to outbreak of vesicular lesions Lesions rupture, crust over, and heal Infectious until it crusts over Treatment: analgesics, calamine lotion, antiviral agents, Zoster vaccine if greater than 60 years Complications: postherpetic neuralgia, eye involvement

vision interventions

Warm incandescent lighting Increase light intensity Control glare Use sunglasses Select colors with good contrast Reading material with large, dark, evenly spaced print Red and orange colors can be seen the best Long-term care: -Cognitive impairment interferes with ability to communicate visual disturbances -If a person has glasses, he or she should wear them -Routine eye care is a gap in care and can lead to functional decline, decreased quality of life, and depression -One-third of vision problems in LTC setting are reversible

Hydration Management

Water is important for thermoregulation and dilution of water-soluble medications, facilitates bowel and renal function, and maintains metabolic processes A significant number of older adults drink less than 1 liter of fluid/day, less than the recommended amount of 1500 mL/day Adequate fluid consumption and maintenance of fluid balance is essential to health Age-related changes: -Thirst sensation diminishes -Creatinine clearance declines -Total body water decreases -Loss of muscle mass and increase in fat cells Other contributing factors include medications, functional impairment, and other comorbid conditions like diabetes

A

What is the #1 treatment of PU? A. Prevention B. Early identification C. Thorough patient history D. Risk assessment

B

What is the estimated number of institutionalized older adults who are unable to eat independently? A. 40% B. 50% C. 60% D. 70%

C

What is the most common sleep disorder? A. OSA insomnia B. Restless leg syndrome C. Insomnia D. Circadian rhythm sleep disorders

D

What is the most common type of hearing loss in the older adult ? A. Conductive B. Noise induced C. Otosclerosis D. Presbycusis

B

What persons have the highest risk for fecal incontinence? A. Persons living in the community B. Persons residing in nursing homes C. Persons in the hospital D. Persons that are younger in age

hyperthermia

When body temperature increases above normal ranges because of environmental or metabolic heat loads is a temperature-related illness and is classified as a medical emergency

D

Which of the following are best practices for communicating with older adults? A. Never assume hearing loss is from age until other causes are ruled out B. Lower your tone of voice, articulate clearly, use a moderate rate of speech C. Inappropriate responses, inattentiveness, and apathy may be signs of hearing loss D. All of the above

D

Which of the following are risk factors for UI? A. High caffeine intake B. Smoking C. Estrogen deficiency D. All of the above

D

Which of the following is NOT an age-related change that affects hydration? A. Thirst sensation diminishes B. Creatinine clearance declines C. Total body water decreases D. Loss of fat cells and increase in muscle mass

B

Which of the following is considered an eye emergency? A. Cataract B. Acute angle closure glaucoma C. Age-related macular degeneration (wet) D. DME

C

Which of the following is the most common malignant skin cancer? A. Melanoma B. Squamous cell carcinoma C. Basal cell carcinoma D. Actinic keratosis

D

Which one of the following is a myth about PEG tubes? A. PEGs do not improve quality of life B. PEGs do not prolong survival in dementia C. PEGs do not reduce the risk of aspiration D. PEGs improve albumin levels and nutritional status

Restless legs syndrome

Willis Ekbom disease Neurological movement disorder of the legs Diagnosis is based on a sleep study

urinary incontinence (UI)

a stigmatized, underreported, underdiagnosed, and undertreated condition that is not a normal part of aging Individuals may not seek treatment because they may be embarrassed or think it is normal is an important but yet neglected geriatric syndrome Viewed as an inconvenience instead of a treatable condition Nurses must take the lead in implementing approaches to continence promotion and public health education Facts and Figures: -Public health problem affecting millions of adults worldwide -Between 2008 and 2018, it is expected that 22% (546 million) of adults will be affected -More common in women and peaks at menopause, and steady increase in aging men -More prevalent than diabetes and Alzheimer's disease -More than $16 billion spent annually in indirect costs Risk factors: -Many risk factors are associated with changes in aging -Dementia is a high-risk factor for UI because a person may not be able to find the bathroom or recognize the urge to void -Drugs that increase urine output, sedatives, tranquilizers, hypnotics that produce drowsiness, confusion, or limited mobility promote incontinence by dulling the transmission or desire to urinate Consequences: -Affects quality of life and has physical, psychosocial, and economic consequences -Associated with increased risk for falls, fractures, and hospitalization -Affects self-esteem and increases risk for depression, anxiety, dignity, autonomy, social isolation, skin breakdown, and sexual activity -Increases the risk for admission to the nursing home in those over 65 years of age -Psychosocial impact affects the person and his or her family caregivers Assessment: -should routinely be addressed on the initial assessment -80% of incontinence can be cured or treated to minimize detrimental affects -Nurses play a key role in identification -Assessment is multidimensional and includes continence patterns, alterations, and contributing factors Interventions -Behavioral (Box 16-7) -Scheduled (timed) voiding (Figure 16-1) -Bladder training -Pelvis floor muscle exercises (Box 16-8) -Vaginal weight training -Lifestyle modifications (Box 16-9) Management: Absorbent products -Protective undergarments or briefs Pharmacological interventions -Not considered first-line treatment -Anticholinergics and antimuscarinics Surgical Interventions -Indicated for stress incontinence -Most common procedures colposuspension and "slings" Nonsurgical devices -Intravaginal or intraurethral devices to relieve stress

transient UI (acute)

a sudden onset, present 6 months or less, and is usually caused by treatable factors, like urinary tract infection (UTI), delirium, constipation, stool impaction, or increased urine production

Presbyopia

decreased near vision -is a common change of aging

Xerophthalmia

excessively dry eyes

mobility

intimately linked to health status and quality of life _______ and comparative degrees of agility are based on muscle strength, flexibility, postural stability, vibratory sensation, cognition, and perceptions of stability Gait and ________ impairments are not an inevitable consequence of aging, but often a result of chronic disease or trauma Impairment of ______ is an early predictor of physical disability and associated with poor outcomes such as falling, loss of independence, depression, decreased quality of life, institutionalization, and death Maintenance and function is an essential component of best practice gerontological nursing and is effective in preventing falls, unnecessary decline, and loss of independence

entropin

inward turning of the lower lid

Obesity (Overnutrition)

is a global epidemic and major public health concern It is associated with increased costs, functional impairments, disability, chronic disease, and admission to nursing home More than a third of persons over 65 years are obese ______ paradox: some research found that persons who survived to 70 years had lower mortality rate if they were overweight

established UI (chronic)

may have sudden or gradual onset and is categorized as: (1) stress, (2) urge, (3) urge, mixed, stress, (4) functional, (5) mixed

ectropion

outward turning of the lower lid