Chronic Illness and Older Adults

Glaucoma

A group of disorders characterized by - Increased IOP and consequences of elevated pressure - Optic nerve atrophy - Peripheral visual field loss 2nd leading cause of blindness in U.S. Leading cause of blindness in African Americans - Many are unaware - Incidence increases with age - Preventable - Genetic traits Blindness from glaucoma is largely preventable with early detection and appropriate treatment. Genetic factors have been identified in some types of glaucoma.

Risk Factors Pressure Ulcers

Advanced age Anemia Contractures Diabetes mellitus Elevated body temperature Friction Individuals at risk include those who are older, incontinent, bed- or wheelchair-bound, or recovering from spinal cord injuries (see Table 11-11). Immobility Impaired circulation Incontinence Low diastolic BP (<60 mm Hg) Mental deterioration Neurologic disorders Obesity Pain Prolonged surgery Vascular disease

Effects of Aging on Drug Metabolism

Age-related changes alter the pharmacodynamics and pharmacokinetics of drugs. Drug-drug, drug-food, and drug-disease interactions all influence the absorption, distribution, metabolism, and excretion of drugs. The most dramatic changes with aging are related to drug metabolism. - Hepatic blood flow decreases markedly. - Enzymes largely responsible for drug metabolism are decreased. - As a result, drug half-life is increased, which leads to greater risk for drug toxicity and adverse drug events. - Overall, by age 75 to 80, there is a 50% decline in the renal clearance of drugs. Medication effects with multiple health problems are particularly challenging. - As one disease is treated, another may be affected. Do a thorough and accurate assessment of medication use and knowledge. - Ask older adults to bring all medications (over-the-counter drugs, prescription drugs, vitamins and supplements, and herbal remedies) that they take regularly or occasionally to their health care appointment. - Use multiple descriptive terms to help stimulate understanding of the various types of pharmaceuticals patients may be taking

Older Adults

Aging population 1. Living Longer - Better drug therapies - Mechanical devices - Improved Surgical Interventions - Declining Infant mortality. The older adult population (65+) continues to outpace the rest of the population. Over 41 million people, or 13% of the population, are age 65+. Nearly one in five U.S. residents is expected to be 65+ by 2030. The fastest-growing segment is people 85+ due to declining infant mortality, new drug therapies, mechanical devices, and improved surgical interventions. Thirteen percent of Americans over 65 are of racial or ethnic minority populations; by 2030 that proportion will increase 125%, while growth in the European-American population will only increase by 54%. Upcoming cohorts of older adults will likely have increased access to higher education, employment, technology, and resources. Those reaching age 65 can expect additional years of life - 17.8 for men - 20.4 for women

Influencing Factors Pressure ulcers

Amount of pressure (intensity) Length of time pressure is exerted (duration) Ability of tissue to tolerate externally applied pressure

Diagnostic Studies Visual System

Amsler grid test A, Normal grid. B, Abnormal grid as seen by person with macular degeneration.

Ophthalmoscopy

As glaucoma progresses, optic disc cupping may be one of the first signs of chronic open-angle glaucoma. The optic disc becomes wider, deeper, and paler (light gray or white), which is visible with direct or indirect ophthalmoscopy.

Assessment Pressure Ulcer

Assess pressure ulcer risk on admission and at periodic intervals based on the patient's condition - Thorough head-to-toe on admission - Periodic reassessment In acute care, a patient should be reassessed every 24 hours. In long-term care, a resident should be reassessed weekly for the first 4 weeks after admission and then minimally monthly or quarterly. In home care, a person should be reassessed every nurse visit.

Clinical Manifestations Macular Degeneration

Blurred or Darkened Vision Scotomas (blind spots) Metamorphopsia (vision distortion)

Inter professional Care Glaucoma

Chronic open-angle glaucoma 1. Drug therapy 2. Argon laser trabeculoplasty - Laser stimulates scarring and contraction of trabecular meshwork 3. Trabeculectomy The primary focus of glaucoma therapy is to keep the IOP low enough to prevent the patient from developing optic nerve damage. Therapy varies with the type of glaucoma. Initial treatment in chronic open-angle glaucoma is with drugs (Table 21-7). The patient must understand that continued treatment and supervision are necessary because the drugs control, but do not cure, glaucoma. Argon laser trabeculoplasty (ALT) is a noninvasive option to lower IOP when medications are not successful, or when the patient either cannot or will not use the drug therapy as recommended. ALT is an outpatient procedure that requires only topical anesthetic. The laser stimulates scarring and contraction of the trabecular meshwork, which opens the outflow channels. ALT reduces IOP most of the time. The patient uses topical corticosteroids for approximately 3 to 5 days after the procedure. The most common complication is an acute postoperative IOP rise. Follow-up exams are scheduled with the ophthalmologist 1 week after the procedure and again 4 to 6 weeks following surgery. Trabeculectomy is a filtration surgery and is indicated when medical management and laser surgery have been unsuccessful.

Special Older Adult Populations

Chronically Ill Older Adults - Incidence of chronic illness triples after age 45 Daily living with chronic illness is a reality for many older adults. Most persons 65 years of age and older live with at least one chronic condition such as hypertension, heart failure, CAD, COPD, cancer, diabetes, and osteoarthritis. Other common chronic conditions include Alzheimer's disease, vision and hearing deficits, osteoporosis, stroke, Parkinson's disease, and depression. Frail Older Adults 1. Clinical manifestations of frailty - Unintentional weight loss - Self-reported exhaustion - Weakness - Slow walking speed - Low level physical activity Frailty is a common clinical syndrome seen in older adults. Clinical manifestations of frailty include three or more of the following criteria: - Unintentional weight loss (greater than or equal to 10 pounds in a year) - Self-reported exhaustion - Weakness (measured by grip strength) - Slow walking speed - Low level of physical activity Risk factors include disability, multiple chronic conditions, and dementia.

Trajectory of Chronic Illness

Corbin and Strauss identified seven tasks of those who are chronically ill: 1. Preventing and managing a crisis 2. Carrying out prescribed treatment regimens 3. Controlling symptoms 4. Re-organizing lifestyle 5. Adjusting to changes in course of disease 6. Preventing social isolation 7. Attempting to normalize interactions with others

Clinical Manifestations Cataracts

Decrease in vision Abnormal color perception Glaring of vision Glare is the result of light scatter caused by lens opacities, and it may be significantly worse at night when the pupil dilates. The visual decline is gradual, but the rate of cataract development varies from patient to patient.

Diagnostic Studies Glaucoma

Diagnostic studies can be completed with slit lamp microscopy, peripheral and central vision tests, and ophthalmoscopy. In open-angle glaucoma, slit lamp microscopy reveals a normal angle Measures of peripheral and central vision provide additional diagnostic information. Central acuity may remain 20/20 even in the presence of severe peripheral visual field loss

Assessment Tools Pressure Ulcer

Do a risk assessment using a validated tool such as the Braden scale for systematic skin inspection Braden scale is available at www.bradenscale.com. Knowing the level of risk can help determine how aggressive preventive measures should be.

Treatment Ulcer Care

Document and describe stage, size, location, exudate, infection, pain, and tissue appearance - Measure length and width - Measure depth Use pressure ulcer healing tool to document healing Careful documentation should be made of the size of the pressure ulcer. A wound-measuring card or tape can be used to note the ulcer's maximum length and width in centimeters. To find the depth of the ulcer, gently place a sterile cotton-tipped applicator into the deepest part of the ulcer. Documentation of the healing wound can be done using several available pressure ulcer healing tools such as the NPUAP Pressure Ulcer Scale for Healing (PUSH) tool. Some agencies require that pictures of the pressure ulcer be taken initially and at regular intervals during the course of treatment. Relieve pressure Decried Cleanse with nontoxic solutions Keep ulcer bed moist Select the appropriate pressure-relieving technique (e.g., pad, overlay, mattress, specialty bed) to relieve pressure and keep the patient off of the pressure ulcer. Whenever possible, do not turn the patient onto a body surface that is still reddened. Massage is contraindicated in the presence of acute inflammation and where there is the possibility of damaged blood vessels or fragile skin. A pressure ulcer that has necrotic tissue or eschar (except for dry, stable necrotic feet or heels) must have the tissue removed by surgical, mechanical, enzymatic, or autolytic debridement methods. Clean pressure ulcers with noncytotoxic solutions (e.g., normal saline) that do not kill or damage cells, especially fibroblasts. Solutions such as Dakin's solution (sodium hypochlorite solution), acetic acid, povidone-iodine, and hydrogen peroxide (H2O2) are cytotoxic and therefore should not be used to clean pressure ulcers. Keep a pressure ulcer slightly moist, rather than dry, to enhance re-epithelialization. It is important to use enough irrigation pressure to adequately clean the pressure ulcer (4 to 15 psi) without causing trauma or damage to the wound. To obtain this pressure, a 30-mL syringe and a 19-gauge needle can be used. After cleaning the ulcer cover it with an appropriate dressing Keep ulcer slightly moist Stage II through IV pressure ulcers are considered contaminated - Assess for signs and symptoms of infection Some factors to consider when selecting a dressing are maintenance of a moist environment, prevention of wound desiccation (drying out), ability to absorb the wound drainage, location of the wound, amount of caregiver time, cost of the dressing, presence of infection, clean versus sterile dressings, and the care delivery setting. Never use a wet-to-dry dressing on a clean granulating pressure ulcer. This type of dressing should be used only for mechanical debridement of a wound that has necrotic or sloughing tissue. The caloric intake needed to correct and maintain nutritional balance may be 30 to 35 calories/kg/day and 1.25 to 1.50 g of protein/kg/day. Maintain adequate nutrition Caloric intake elevated to 30 to 35 cal/kg/day or 1.25 to 1.50 g protein/kg/day - Supplements, enteral, or parenteral feedings may be necessary The maintenance of adequate nutrition is an important nursing responsibility for the patient with a pressure ulcer. Often, the patient is debilitated and has a poor appetite secondary to inactivity. Enteral feedings can be used to supplement the oral feedings. If necessary, parenteral nutrition consisting of amino acid and glucose solutions is used when oral and enteral feedings are inadequate.

Nursing Management Planning Glaucoma

Expected Goals - No progression of visual impairment - Understanding of disease process and rationale for therapy - Compliance with all aspects of therapy - No postoperative complications

Nursing Management Evaluation Glaucoma

Expected Outcomes - No further loss of vision - Compliance with recommended therapy - Safe functioning in the environment - Pain relief from disease and surgery

Structures and Functions Visual System

External structures and functions 1. Eyebrows 2. Eyelids 3. Eyelashes - Serve as a physical barrier primarily for protection of eyeball or globe The eyebrows, eyelids, and eyelashes serve an important role in protecting the eye. They provide a physical barrier to dust and foreign particles. The eye is further protected by the surrounding bony orbit and by fat pads located below and behind the globe, or eyeball. Structures and functions of vision 1. Refraction 2. Refractive errors - Myopia - Hyperopia - Astigmatism - Presbyopia Refraction is the ability of the eye to bend light rays so that they fall on the retina. When light does not focus properly, it is called a refractive error. 1. Types of refractive errors are myopia (nearsightedness) and hyperopia (farsightedness). 2. Astigmatism is an uneven curvature of the cornea, which results in visual distortion. 3. Presbyopia is a loss of accommodation resulting in an inability to focus on near objects. - Manifestations of presbyopia appear around age 40. External structures and functions 1. Medial and lateral acanthi 2. Cranial nerves (III and VII) 3. Conjunctiva - Tears 4. Sclera - "White" of the eye The upper and lower eyelids join at the medial and lateral canthi. The eyelids open by action of the cranial nerve (CN) III (oculomotor nerve) and close through the action of muscles innervated by cranial nerve (CN) VII (facial nerve). The conjunctiva is a transparent mucous membrane that covers the inner surfaces of the eyelids and extends over the sclera, forming a "pocket" under each eyelid. - Glands in the conjunctiva secrete mucus and tears. - Blinking of the upper eyelid distributes tears over the anterior surface of the eyeball and nourishes the surface cells. The sclera comprises collagen fibers meshed together to form an opaque structure. - Commonly referred to as the "white" of the eye - Forms a tough shell that helps protect the intraocular structures The small round opening in the center is the pupil. 1. It is through the pupil that light enters the eye. 2. The pupil dilates and constricts via two muscles controlled by cranial nerves V and III: - V = Trigeminal nerve - III = Oculomotor nerve External eye and lacrimal apparatus. Tears produced in the lacrimal gland pass over the surface of the eye and enter the lacrimal canal. From there the tears are carried through the nasolacrimal duct to the nasal cavity. Every structure of the visual system is subject to changes with aging. - Some of these changes are benign, but others can lead to serious loss of vision. - Poor vision and blindness can have significant psychosocial implications. Age-related changes in the visual system and differences in assessment findings are presented in Table 20 -1.

Biologic Aging

From a biologic view, aging reflects the changes that occur over time. - Genetics, diet, and environment contribute to the process of aging. - Biologic aging is a balance of positive and negative factors. Current research is directed at increasing both life span and quality of life. The hope is for new anti-aging therapies that slow down or reverse changes leading to chronic illness and disability. More research is needed before it is determined whether nutritional supplements or vitamins will delay aging or enhance day-to-day function of older adults.

Clinical Manifestations Stage IV

Full-thickness loss can extend to muscle, bone, or supporting structures Bone, tendon, or muscle may be visible or palpable Slough or eschar may be present on some parts of the wound bed. Undermining and tunneling may also occur

Clinical Manifestations Stage III

Full-thickness skin loss Subcutaneous tissue may be visible but bone, tendon, or muscle are not. Presents as deep crater with possible undermining of adjacent tissue Ulcer depth ulcer varies by location The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue, and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable.

Clinical Manifestations Unstageable Ulcer

Full-thickness tissue loss in which actual depth of ulcer is completely obscured by slough or eschar Slough is yellow, tan, gray, green, or brown whereas eschar appears tan, brown, or black in the wound bed. Slough or eschar must be removed to expose the base of the wound for true depth to be determined Stable (dry, adherent, intact without erythema, or fluctuance) eschar on the heels serves as "the body's natural (biologic) cover" and should not be removed.

Nursing Management Nursing Implementation Glaucoma

Health Promotion - Teach patient and family risks of glaucoma, and that it increases with age - Emphasize importance of early detection and treatment - Provide ophthalmologic examinations Loss of vision because of glaucoma is a preventable problem. Teach the patient and family about the risk of glaucoma, and that it increases with age. Emphasize the importance of early detection and treatment in preventing visual impairment. A comprehensive ophthalmic examination is important in identifying persons with glaucoma and those at risk of developing glaucoma. The current recommendation is for an ophthalmologic examination every 2 to 4 years for persons between ages 40 and 64 years, and every 1 to 2 years for persons age 65 years or older. African Americans in every age category should have examinations more often because of the increased incidence and more aggressive course of glaucoma in these individuals.

Nursing Management Implementation Cataracts

Health Promotion - Wear sunglasses - Avoid unnecessary radiation - Ensure adequate antioxidant vitamins - Ensure good nutrition No measures have been proven to prevent cataract development. However, it probably is wise (and certainly does no harm) to suggest that the patient wear sunglasses, avoid extraneous or unnecessary radiation, and maintain appropriate intake of antioxidant vitamins (e.g., vitamins C and E) and ensure good nutrition. Also provide information about vision enhancement techniques for the patient who chooses not to have surgery.

Diagnostic Studies Cataracts

History and physical examination Visual acuity measurement Ophthalmoscopy Slit lamp microscope Glare testing Diagnosis is based on decreased visual acuity or other complaints of visual dysfunction. The opacity is directly observable by ophthalmoscopic or slit lamp microscopic examination. A totally opaque lens creates the appearance of a white pupil. See Table 21-2 for other diagnostic studies helpful in evaluating cataracts.

Chronic Illness

Illness can be categorized as either acute or chronic. Chronic illnesses are those that are prolonged, do not resolve spontaneously, and are rarely cured completely. Chronic diseases account for 70% of all deaths in the United States. As the population ages, more older adults are living with more than one chronic illness (frequently up to 6 or more) and experience limitations in physical functioning, work productivity, and quality of life. - Almost one out of 10 Americans experiences major limitations in ADLs. - The lives of patients, families, and caregivers can be greatly affected. - A significant portion of U.S. health care dollars goes toward the treatment of chronic illnesses. Other societal changes contributing to the increase in chronic illnesses include - Insufficient physical activity - Lack of access to fresh fruits and vegetables - Tobacco use - Alcohol consumption. Chronic Illness may have times of acute exacerbation of symptoms To Prevent = Teaching Patient and Family - Adhere to prescribed treatment - Know Signs/Symptoms - Plan to manage the crisis. An acute exacerbation of symptoms may result in further disability or death. Major task for both the patient and caregiver is to learn to prevent or manage the crisis. 1. The patient and caregiver need to understand the potential for the crisis to occur. 2. They need to know ways to prevent or modify the threat. - Often involves adherence to prescribed treatment - Need to know signs and symptoms of the onset of a crisis, which can occur suddenly or slowly - Need to have a plan to manage the crisis that is likely to occur Change in Lifestyle - Timing - Change in daily routine - Leads to social Isolation - Adjusting to the course of the Disease. Treatment regimens vary in degree of difficulty and the impact they have on the person's lifestyle. Learning to control symptoms so that desired activities may be continued is an important - Some individuals redesign their lifestyle by learning to plan ahead. - Others redesign their living space. - The patient and family and/or caregiver need to learn about the pattern of symptoms so that lifestyle may be changed accordingly while maintaining safety. People with chronic illness often report having too much or too little time. Treatment plans that require large amounts of time for the person, as well as caregivers, may necessitate scheduling changes or eliminating other activities. Some diseases have unpredictable courses that make planning activities difficult. Part of the patient's task is to develop a personal identity to include the chronic illness and adjust to the lifestyle changes it necessitates. Social isolation may occur because the individual chooses to withdraw from previous activities or because others withdraw from the chronically ill person. Most individuals with chronic illness attempt to manage symptoms so that they can hide their disabilities or disfigurement. Think: Altered Body Image, Loss of Control, Care Giver Role Strain. Story: Nutritionist just an experimental study where she pretended to have diabetes and learned what it was always like to stab yourself. Prevention of Chronic Illness 1. Preventive health behaviors —voluntary actions taken by an individual or group to decrease the potential threat of illness - Primary - Secondary - Tertiary Chronic illnesses are often preventable. Preventive health behaviors - Primary prevention refers to measures that prevent the occurrence of a specific disease (proper diet, exercise, immunizations). - Secondary prevention refers to actions aimed at early detection of disease that can lead to interventions to prevent disease progression. - Tertiary prevention refers to activities (e.g., rehabilitation) that limit disease progression or return the patient to optimal functioning.

Nursing and Interprofessional Management Pressure Ulcer

In 1859 Florence Nightingale wrote, "If he has a bedsore, it's generally not the fault of the disease, but of the nursing." Her comment emphasizes the critical role that nurses have in prevention and treatment of pressure ulcers. Nursing and interprofessional management are discussed together because the activities are interrelated.

Etiology and Pathophysiology

Influencing factors - Age - Blunt trauma - Congenital factors - Radiation/UV light exposure - Long-term corticosteroid use - Ocular inflammation Most are Age Related Others factors: - blunt or penetrating trauma - congenital factors such as maternal rubella, radiation or ultraviolet (UV) light exposure - certain drugs such as systemic corticosteroids or long-term topical corticosteroids - ocular inflammation. Patient with diabetes mellitus tends to develop cataracts at a younger age.

Clinical Manifestations Stage I

Intact skin with non-blanchable redness of a localized area usually over bony prominence Darkly pigmented skin may not have visible blanching. Its color may differ from the surrounding area. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue.

Pressure Ulcer

Localized injury to skin and/or underlying tissue (usually over bony prominences) Results from pressure or pressure in combination with shear Pressure ulcers generally fall under the category of healing by secondary intention.

Assessment of Patients with Dark Skin

Look for areas of skin darker (purplish, brownish, bluish) than surrounding skin Use natural or halogen light for accurate assessment (fluorescent light casts a blue color that can skew results) Assess skin temperature using your hand - An ulceration may feel warm initially, then become cooler Touch the skin to feel its consistency - Boggy or edematous tissue may indicate a stage I pressure ulcer Ask about pain or an itchy sensation

Treatment for Wet Macular Degeneration

Medication Injected into the vitreous Cavity 1. Ranibizumba 2. Bevacizumba 3. Aflibercept 4. Pegaptanib Medications help to slow down vision loss and are injected every 4-6 weeks depending on treatment response.

Prevention Pressure Ulcers

Mobilize Assistive devices do not replace the need for frequent repositioning and mobilizing the patient.

DRY vs WET Macular degeneration

Most Common Dry - Close vision tasks are more difficult - SLOW, Progressive Vision Loss Wet - More Severe - Related to Blindness - Abnormal blood vessels in or near macula.

Macular Degeneration

Most common cause of irreversible central vision loss in people over 60 in the United States.

Incidence

Most common sites 1. Sacrum 2. Heels Pressure ulcers usually occur over bony prominences.

Complications Pressure Ulcer

Most common—Recurrence Cellulitis Chronic infection Osteomyelitis Possible death

Inter professional Care Cataracts

Nonsurgical therapy 1. No nonsurgical "cure" 2. Visual aids - Changing eyewear prescription - Reading glasses - Magnifiers - Increased lighting The presence of a cataract does not necessarily indicate the need for surgery. For many patients, the diagnosis is made long before they actually decide to have surgery. Nonsurgical therapy may postpone the need for surgery. The patient may be willing to adjust his or her lifestyle to accommodate for visual decline. For example, if glare makes it difficult to drive at night, a patient may elect to drive only during daylight hours or to have a family member drive at night. Sometimes informing and reassuring the patient about the disease process makes the patient comfortable about choosing nonsurgical measures, at least temporarily.

Nursing Management

Nurses play a critical role - Conducting a comprehensive history and physical assessment - Participating in plan of care - Teaching patient and caregiver -Symptom management - Evaluating patient and family outcomes The course of chronic illness is often unpredictable. Diagnosis and treatment of the acute phase or acute exacerbations of a chronic illness are sometimes done in a hospital. Other phases are regularly assessed and managed in an ambulatory care setting, at home, in an assisted living facility, or in a skilled nursing facility. Management of the illness can profoundly affect patient, family, and caregiver's ADLs and lifestyles. Assessment (at least annually) includes ADLs, IADLs, and perception of relative health/illness and level of function. Self-management is an individual's ability to manage symptoms, medications and treatment, physical and psychosocial consequences, and lifestyle changes in response to living with a chronic illness. Ideally, collaboration begins at the time of diagnosis under the direction of the health care team, and then family caregivers learn to work together with the patient. Situation may be complicated if caregivers are also older and chronically ill.

Evaluation

The evaluation phase of the nursing process is similar for all patients. The results of evaluation direct you to continue the plan of care or revise as indicated. Remember — when evaluating nursing care with older adults, the focus is on functional improvement and quality of life.

Nursing Management

Nursing Implementation 1. Depression - Not a normal part of aging - Second highest rate of suicide occurs in those over 75 - Occurs together with medical conditions Depression is the most common mood disorder in older adults. - Fifteen percent of those living at home have manifestations of depression. - Higher rates in institutional settings - The second highest rate of suicide occurs in those over 75. Depression is associated with female gender, divorced or separated marital status, low socioeconomic status, poor social support, and a recent adverse and unexpected event. Pain, insomnia, lethargy, agitation, weight loss, and dementia are associated with depression. Late-life depression often occurs together with medical conditions and can exacerbate medical conditions by affecting adherence with diet, exercise, or drug regimens. It is important to rule out physical disorders that have symptoms similar to depression — thyroid disorders and vitamin deficiencies. Older adults with depression may feel unworthy, withdrawn, and isolated. It is important that you assist patients and caregivers who exhibit depressive symptoms to get help

Cataract

Opacity within the lens - May occur in one or both eyes Cataract removal is most common surgical procedure in United States If present in both eyes, one cataract may affect the patient's vision more than the other.

Planning (Pressure Ulcers)

Overall Goals - No deterioration of the ulcer - Reduce contributing factors - Not develop an infection - Have healing - Have no recurrence

Clinical Manifestations Glaucoma

POAG - Develops slowly - No symptoms - Unnoticed until peripheral vision is severely compromised Eventually the patient with untreated glaucoma has "tunnel vision," in which only a small center field can be seen and all peripheral vision is absent. Acute angle-closure glaucoma 1. Sudden onset - Excruciating pain in or around eyes - Nausea and vomiting - Seeing colored halos around lights - Blurred vision - Ocular redness PACG causes sudden and definite symptoms. Manifestations of subacute or chronic angle-closure glaucoma appear more gradually. - The patient who has had a previous, unrecognized episode of subacute angle-closure glaucoma may report a history of blurred vision, seeing colored halos around lights, ocular redness, or eye or brow pain. IOP elevated in glaucoma - Normal IOP 10 to 21 mm Hg - Open-angle glaucoma 22 to 32 mm Hg - Acute angle-closure glaucoma >50 mm Hg IOP is usually elevated in glaucoma. - Normal IOP is 10 to 21 mm Hg. - In the patient with elevated pressures, the ophthalmologist usually will repeat the measurements over a period of time to verify the elevation. - In open-angle glaucoma, IOP is usually between 22 and 32 mm Hg. - In acute angle-closure glaucoma, IOP may be >50 mm Hg.

Clinical Manifestations Stage II

Partial-thickness loss of dermis Shallow open ulcer with red pink wound bed Presents as an intact or ruptured serum-filled blister Presents as a shiny or dry shallow ulcer without slough or bruising. (Bruising indicates deep tissue injury.)

Subjective Data for Visual System

Past medical history Medications Family History Gender/Ethnicity/Age Preventative care/Safety Functions of ADLS Past Medical History: - HTN - Headaches - Diabetes - Tearing Medications: - Antihistamine or decongestants can cause ocular dryness. Family History: - Glaucoma and Macular Degeneration have genetic link Patient characteristics such as gender, ethnicity, and age are important in assessing ophthalmic conditions. - Men are more likely than women to have color blindness. - The leading cause of blindness among African Americans is glaucoma. - Older individuals are also at greater risk for glaucoma. Prevention/Safety: - Using protective eyewear during hazardous activities - Avoiding noxious fumes or other eye irritants - Using sunglasses in bright light - Problems with night driving - Appropriate use and care of contact lenses Function of ADLs: - Falls - Ability to Perform Self-care

Objective Data of Auditory System

Physical examination - Balance r/t inner ear - Deformities of external ear Assessment of the auditory system should include assessment of hearing and equilibrium, because problems with balance may present as nystagmus or vertigo. Auditory assessment notes head posturing and appropriateness of responses when speaking to the patient.

Objective Data for Visual System

Physical examination (May require special training) - Assess the Structures - Visual fields Physical examination of the visual system includes inspecting the ocular structures and determining the status of their respective functions. - Eyebrows, eyelashes, and eyelids - Conjunctiva and sclera - The cornea should be clear, transparent, and shiny. - The iris should appear flat and not bulge toward the cornea. - The area between the cornea and iris should be clear, with no blood or purulent material visible in the anterior chamber. - Both irides should be of similar color and shape. - A color difference between the irides occurs normally in a small portion of the population. - An ophthalmoscope is used to magnify the retina and optic nerves and bring them into crisp focus. Physiologic functional assessment includes: (1) determining the patient's visual acuity, ability to judge closeness and distance, and extraocular muscle (EOM) function (2) evaluating visual fields (3) observing pupil function Assessment of ocular structures should include examining the ocular adnexa, external eye, and internal structures.

Nursing Management Planning Cataracts

Postoperative goals - Understand and comply with postoperative therapy - Maintain level of comfort - Remain free of infection and other complications Preoperatively, the overall goals are that the patient with a cataract will (1) make informed decisions regarding therapeutic options and (2) experience minimal anxiety. Teach about S/S of infection Decreased depth perception with eye patch

Surgical Therapy

Preoperative phase - Eye drops - Dilate eyes and decrease Inflammation Intraoperative phase - Phacoemulsify - Extracapsular Cataract Extraction Postoperative The patient will receive dilating drops and a nonsteroidal antiinflammatory eye drop to reduce inflammation. Intraoperative: 1. Phacoemulsify - A very small incision is made in the surface of the eye in or near the cornea. - A thin ultrasound probe is inserted into the eye and ultrasonic vibrations are used to dissolve (phacoemulsify) the clouded lens into fragments. - These pieces are then suctioned out through the same ultrasound probe. - The small incisions are self-sealing and usually do not require sutures. An extracapsular cataract extraction: - procedure is used mainly for very advanced cataracts where the lens is too dense to dissolve into fragments. - Requires a larger incision so that the cataract can be removed in one piece without being fragmented inside the eye. - Requires sutures to close the larger wound, and visual recovery is often slower. Postoperative phase - Outpatient procedure unless complications occur - Antibiotic and corticosteroid eye drops - Limiting activities - Follow-up visits

Gerontologic Considerations Effects of Aging on Auditory System

Presbycusis - Hearing loss as a result of aging - Many sources Tinnitus Prevalence expected to rise as life span increases Approximately 20% of American adults report some degree of hearing loss. Presbycusis (hearing loss) can result from aging or a variety of sources, such as noise exposure, systemic disease, poor nutrition, ototoxic drugs, buildup of ear wax, and pollution. - Usually greater for high-pitched sounds Tinnitus (ringing in the ears) may accompany the hearing loss that results from the aging process. Age-related changes of the auditory system can result in impaired hearing, which can have serious implications for quality of life, including psychosocial and physical dysfunction.

Health Promotion

Primary nursing responsibility - Identification of patients at risk - Implementation of pressure ulcer prevention strategies Implementing evidence-based pressure ulcer prevention programs can reduce the occurrence of health care-acquired pressure ulcers. Use devices to reduce pressure and shearing force (e.g., low-air-loss mattresses, foam mattresses, wheelchair cushions, padded commode seats, boots [foam, air], lift sheets) as appropriate. These devices do not replace the need for frequent repositioning. In the past the "standard" was to turn and reposition patients every 2 hours. However, this "policy" is not evidence based. Time schedules and frequency should be individualized based on risk factors, patient's overall condition, and type of mattress and support surface.

Etiology and Pathophysiology Glaucoma

Primary open-angle glaucoma (POAG) - Most common type of glaucoma - Outflow of aqueous humor is ↓ in trabecular meshwork In POAG, the outflow of aqueous humor is decreased in the trabecular meshwork. In essence, the drainage channels become clogged, like a clogged kitchen sink. Damage to the optic nerve can then result. Primary angle-closure glaucoma (PACG) - Angle closure ↓ the flow of aqueous humor - Caused by age, pupil dilation - Possibly drug induced Primary angle-closure glaucoma (PACG) is caused by a reduction in the outflow of aqueous humor that results from angle closure. Usually, this is caused from the lens bulging forward as a result of the aging process. Angle closure may also occur as a result of pupil dilation in the patient with anatomically narrow angles. An acute attack may be precipitated by situations in which the pupil remains in a partially dilated state long enough to cause an acute and significant rise in IOP. This may occur because of drug-induced mydriasis, emotional excitement, or darkness. Drug-induced mydriasis may occur not only from topical ophthalmic preparations but also from many systemic medications (both prescription drugs and over-the-counter [OTC] drugs). Check drug records and documentation before administering medications to the patient with angle-closure glaucoma, and instruct the patient not to take any mydriatic-producing medications.

Prevention Skin Care

Remove excessive moisture Avoid massage over bony prominences Use lift sheets Position with pillows or elbow and heel protectors Use specialty beds Cleanse skin if incontinence occurs - Use pads or briefs that are absorbent

Risk Factors Macular Degeneration

Retinal Aging Genetics/Family History White Ethnicity Chronic Inflammation Condition Smoking Hypertension Nutritional Factors Dietary Supplements of vitamin C, vitamin E, lutein, zeaxanthin, and zinc decrease progression.

Contributing Factors Pressure Ulcers

Shearing force: Pressure exerted on skin when it adheres to bed and skin layers slide in direction of body movement Moisture: Excessive increases risk for skin breakdown Pulling a patient up in bed can create a shearing force.

Clinical Manifestations Infection Pressure Ulcer

Signs - Leukocytosis - Fever - Increased ulcer size, odor, or drainage - Necrotic tissue - Indurated, warm, painful

Treatment Operative Repair

Skin grafts Skin flaps Musculocutaneous flaps Free flaps Once the pressure ulcer has been successfully debrided and has a clean granulating base, the goal is to provide an appropriate wound environment that supports moist wound healing and prevents disruption of the newly formed granulation tissue. Reconstruction of the pressure ulcer site by surgical repair, including skin grafting, skin flaps, musculocutaneous flaps, or free flaps, may be necessary.

Nursing Management

Specific elements including ADLs and IADLs, mental status evaluation, social-environmental assessment, and physical assessment. Evaluation of mental status is particularly important for older adults because these results often determine the potential for independent living. A through assessment of fall risk, including fear of falling and causes of past falls is important. The goal is to plan and implement actions that help older adults remain as functionally independent as possible and to promote their quality of life. SPICES, an effective tool for obtaining assessment data in older adults, may be used as an initial nursing assessment when working in any setting. S- sleep disorders P- problems with eating or feeding I- incontinence C- confusion E- evidence of falls S- skin breakdown Evaluation of the results of a comprehensive nursing assessment helps determine the service and potential long-term placement needs of older adults. Nursing Implementation - Acute and Ambulatory Care The hospital may be the first point of contact for older adults with the health care system. Conditions that most commonly result in hospitalization include falls, dysrhythmias, heart failure, stroke, fluid and electrolyte imbalances (e.g., hyponatremia, dehydration), pneumonia, urosepsis, and hip fractures. Older adults are often hospitalized with multiple problems. The outcome of hospitalization for older adults varies. Of particular concern are patients undergoing high risk surgical procedures and those who experience delirium while hospitalized. Nursing Implementation - Medication use Medication use in older adults requires thorough and regular assessment, care planning, and evaluation. Older adults may have difficulty due to cognitive impairment, altered sensory perceptions, limited hand mobility, and the high cost of many prescriptions. Nonadherence to medication regimens is common. Many older adults are unable to read prescription drug labels or understand the health information that is provided to them. Older adults may have difficulty managing medication regimens due to cognitive impairment, altered sensory perceptions, limited hand mobility or dexterity, and the high cost of many drugs. Polypharmacy, overdose, and addiction to prescription drugs are major causes of illness in older adults. Errors from (1) administration of both brand and generic medications, (2) refilling medications too soon or too late resulting in taking the medication incorrectly, and (3) drug-drug interactions can be prevented by having a pharmacist review the medication regimen regularly. The American Geriatrics Society Beers Criteria are designed to reduce problems with medications in older adults.

Serious Reportable Event

Stage 3 or 4 (full skin thickness injury) pressure ulcer acquired after admission to a health care setting is considered a serious reportable event (SRE) (never event)

Nursing Management Gerontologic Considerations

Tend to special needs of older adult - Caution about potential drug interactions that occur with systemic illnesses and their treatments - Teach that occluding puncta will limit systemic absorption of glaucoma medications Many older patients with glaucoma have systemic illnesses or take systemic medications that may affect their therapy. In particular, the patient using a β-adrenergic blocking glaucoma agent may experience an additive effect if a systemic β-adrenergic blocking drug is also being taken. All β-adrenergic blocking glaucoma agents are contraindicated in the patient with bradycardia, heart block greater than first-degree heart block, cardiogenic shock, and overt cardiac failure. The noncardioselective β-adrenergic blocker glaucoma agents are also contraindicated in the patient with chronic obstructive pulmonary disease (COPD) or asthma. The hyperosmolar agents may precipitate heart failure or pulmonary edema in the susceptible patient. The older patient on high-dose aspirin therapy for rheumatoid arthritis should not take carbonic anhydrase inhibitors. The α-adrenergic agonists can cause tachycardia or hypertension, which may have serious consequences in the older patient. Teach the older patient to occlude the puncta to limit the systemic absorption of glaucoma medications

Structures and Functions Auditory System

The auditory system consists of peripheral and central systems. The peripheral system includes the external, middle, and inner ear and is involved with sound reception and perception. The central system (brain and its pathways) integrates and assigns meaning to what is heard. The external ear consists of the auricle (pinna), external auditory canal, and tympanic membrane. - The auricle is composed of cartilage and connective tissue. - The external auditory canal is a slightly S-shaped tube about 1 in. (2.5 cm) in length. - The proximal 1/3 of the canal is lined with fine hairs (cilia), sebaceous (oil) glands, and ceruminous (wax) glands. - The distal 2/3 of the canal is lined with thin epithelium over the bone, and is very sensitive. - The function of the external ear and canal is to collect and transmit sound waves to the tympanic membrane. - The eardrum is a shiny, translucent, pearl-gray membrane that serves as a partition and an instrument of sound transmission between the external auditory canal and middle ear.

Eyeball

The eyeball, or globe, comprises three layers. - Sclera and Cornea - Uveal Tract - Retina The tough outer layer comprises the sclera and the transparent cornea. The middle layer consists of the uveal tract (iris, choroid, and ciliary body). The innermost layer is the retina. The anterior cavity is divided into the anterior and posterior chambers. - The anterior chamber lies between the iris and the posterior surface of the cornea - The posterior chamber lies between the anterior surface of the lens and the posterior surface of the iris. - Aqueous humor is a clear watery fluid that fills the anterior and posterior chambers of the anterior cavity of the eye. - It is produced from capillary blood in the ciliary body and drained away by scleral veins (canal of Schlemm) back to the body. The posterior cavity lies in the large space behind the lens and in front of the retina.

Nursing Assessment Visual System

The visual system consists of the external tissues and structures surrounding the eye, external and internal structures of the eye, refractive media, and visual pathway in the brain. The entire visual system is important for visual function.

Clinical Manifestations Pressure Ulcers

Ulcers are staged or categorized based on visible or palpable tissue in ulcer bed: - Stage I (minor) to stage IV (severe) - Slough or eschar may have to be removed for accurate staging of some ulcers

Subjective Data for Hearing

Vertigo Past health history of childhood illnesses Problems of organs adjacent to ear Ototoxic medications Surgery of ear or other treatments Patient information obtained should include specific diseases and medications known to cause hearing problems. 1. Frequency of acute otitis media 2. Surgical procedures (myringotomy, tympanoplasty, tonsillectomy, adenoidectomy) 3. Perforations of the eardrum 4. Draining 5. History of mumps, measles, or scarlet fever Patient information obtained should include specific diseases and medications known to cause hearing problems. 1. Frequency of acute otitis media 2. Surgical procedures (myringotomy, tympanoplasty, tonsillectomy, adenoidectomy) 3. Perforations of the eardrum 4. Draining 5. History of mumps, measles, or scarlet fever Use of ototoxic (damage to CN VIII) drugs such as aspirin, antibiotics, chemotherapy agents, diuretics, and NSAIDs can cause hearing loss, tinnitus, and vertigo but may be reversible if treatment is stopped. Previous wax impaction or surgery, including myringotomy, tympanoplasty, tonsillectomy, or adenoidectomy, should be noted.