Nursing Lifespan of Older Adults
a
A 63-year-old patient is retiring from his job at an accounting firm where he was in a management role for the past 20 years. He has been with the same company for 42 years and was a dedicated employee. His wife is a homemaker. She raised their five children, babysits for her grandchildren as needed, and belongs to numerous church committees. What are the major concerns for this patient? (Select all that apply.) a The loss of his work role b The risk of social isolation c A determination if the wife will need to start working d How the wife expects household tasks to be divided in the home in retirement e The age the patient chose to retire
a, d, e
A 71-year-old patient enters the emergency department after falling down stairs in the home. The nurse is conducting a fall history with the patient and his wife. They live in a one-level ranch home. He has had diabetes for over 15 years and experiences some numbness in his feet. He wears bifocal glasses. His blood pressure is stable at 130/70. The patient does not exercise regularly and states that he experiences weakness in his legs when climbing stairs. He is alert, oriented, and able to answer questions clearly. What are the fall risk factors for this patient? (Select all that apply.) a Impaired vision b Residence design c Blood pressure d Leg weakness e Exercise history
b, c, e
A nurse is caring for a patient preparing for discharge from the hospital the next day. The patient does not read. His family caregiver will be visiting before discharge. What can the nurse do to facilitate the patient's understanding of his discharge instructions? (Select all that apply.) a Yell so the patient can hear you. b Sit facing the patient so he is able to watch your lip movements and facial expressions. c Present one idea or concept at a time. d Send a written copy of the instructions home with him and tell him to have the family review them. e Include the family caregiver in the teaching session.
b, c, e
A nurse is participating in a health and wellness event at the local community center. A woman approaches and relates that she is worried that her widowed father is becoming more functionally impaired and may need to move in with her. The nurse inquires about his ability to complete activities of daily living (ADLs). ADLs include independence with: (Select all that apply.) a Driving. b Toileting. c Bathing. d Daily exercise. e Eating.
d
A nursing student is caring for a 78-year-old patient with multiple sclerosis. The patient has had an indwelling Foley catheter in for 3 days. Eight hours ago the patient's temperature was 37.1° C (98.8° F). The student reports her recent assessment to the registered nurse (RN): the patient's temperature is 37.2° C (99° F); the Foley catheter is still in place, draining dark urine; and the patient is uncertain what time of day it is. From what the RN knows about presentation of symptoms in older adults, what should he recommend first? a Tell the student that temporary confusion is normal and simply requires reorientation b Tell the student to increase the patient's fluid intake since the urine is concentrated c Tell the student that her assessment findings are normal for an older adult d Tell the student that he will notify the patient's health care provider of the findings and recommend a urine culture
b, c, e
A patient's family member is considering having her mother placed in a nursing center. The nurse has talked with the family before and knows that this is a difficult decision. Which of the following criteria does the nurse recommend in choosing a nursing center? (Select all that apply.) a The center needs to be clean, and rooms should look like a hospital room. b Adequate staffing is available on all shifts. c Social activities are available for all residents. d The center provides three meals daily with a set menu and serving schedule. e Staff encourage family involvement in care planning and assisting with physical care.
delirium
Acute confusional state (usually curable). s potentially a reversible cognitive impairment that often has a physiological cause, which can include electrolyte imbalances, untreated pain, infection, cerebral anoxia, hypoglycemia, medication effects, tumors, subdural hematomas, and cerebrovascular infarction or hemorrhage. May accompany systemic infections, pneumonia, or UTI. May also be caused by sensory deprivation or overstimulation, unfamiliar surroundings, or sleep deprivation or psychosocial factors such as emotional distress. It is possible for delirium and dementia to occur at the same time. The presence of delirium is a medical emergency and requires prompt assessment and intervention.
developmental tasks for older adults
Adjusting to decreasing health & physical strength Adjusting to retirement & reduced/fixed income Adjusting to death of spouse, children, siblings, friends Accepting self as aging Maintaining satisfactory living arrangements Redefining relationships with children & siblings Finding ways to maintain quality of life How older adults adjust to the changes of aging is highly individualized. Be sensitive to the effect of losses on older adults and their families and be prepared to offer support. Older adults need to adjust to the physical changes that accompany aging. Some older adults, both men and women, find it difficult to accept aging. Acceptance of personal aging does not mean retreat into inactivity, but it does require a realistic review of strengths and limitations. Need to cope with retirement, residence change, and death of loved ones. All require an extended period of adjustment, during which assistance and support from health care professionals, friends, and family members are necessary. Deaths represent both losses and reminders of personal mortality. Coming to terms with them is often difficult. By helping older adults through the grieving process. A variety of issues sometimes occur, including control of decision making, dependence, conflict, guilt, and loss. How these issues surface in situations and how they are resolved depend in part on the past relationship between the older adult and their adult children. As adult children and aging parents negotiate the aspects of changing roles, nurses are in the position to act as counselors for the entire family. Helping older adults maintain their quality of life is often a priority. What defines quality of life is unique for each person.
validation therapy
Agreement with statements of time, place, and person/communication w/confused older Adult. is an alternative approach to communication with a confused older adult. Reality orientation insists that the confused older adult agree with your statements of time, place, and person; validation therapy accepts the description of time and place as stated by the confused older adult. Validation does not involve reinforcing the older adult's misperceptions; it reflects sensitivity to hidden meanings in statements and behaviors.
nutrition
Appropriate caloric intake, limit fat, salt, sugar
reality orientation
Awareness of time, place, person for restoring sense of reality. is a communication technique that makes an older adult more aware of time, place, and person. The purposes of reality orientation include restoring a sense of reality; improving the level of awareness, promoting socialization; elevating independent functioning; and minimizing confusion, disorientation, and physical regression. The key elements of reality orientation include frequent reminders of person, place, and time; the use of familiar environmental aids such as clocks, calendars, and personal belongings; and stability of the environment, routine, and staff.
exercise
Builds endurance, increases muscle tone, reduces stress
reminiscence
Recalling the past to bring meaning & understanding to present. Assesses self-esteem, cognitive function, coping, emotional stability. (recalling the past) uses the recollection of the past to bring meaning and understanding to the present and to resolve current conflicts. It helps with coping. During the assessment process use reminiscence to assess self-esteem, cognitive function, emotional stability, unresolved conflicts, coping ability, and expectations for the future.
thorax and lungs
Respiratory muscle strength decreases Anteroposterior diameter of thorax increases Because of changes in the musculoskeletal system, the configuration of the thorax sometimes changes. Vertebral changes caused by osteoporosis lead to dorsal kyphosis, the curvature of the thoracic spine. Calcification of the costal cartilage causes decreased mobility of the ribs. The chest wall gradually becomes stiffer. Lung expansion decreases, and the person is less able to cough deeply. If kyphosis or chronic obstructive lung disease is present, breath sounds become distant. Older adult is more susceptible to pneumonia and other bacterial or viral infections.
retirement
Role changes in family/planning
touch
Sensory stimulation, relaxation, comfort, communicates caring. provides sensory stimulation, induces relaxation, provides physical and emotional comfort, orients the person to reality, shows warmth, and communicates interest.
d
Sexuality is maintained throughout our lives. Which of the following answers best explains sexuality in an older adult? a When the sexual partner passes away, the survivor no longer feels sexual. b A decrease in an older adult's libido occurs. c Any outward expression of sexuality suggests that the older adult is having a developmental problem. d All older adults, whether healthy or frail, need to express sexual feelings.
integumentary system
Skin Lesions With aging the skin loses resilience and moisture. The epithelial layer thins, and elastic collagen fibers shrink and become rigid. Wrinkles of the face and neck reflect lifelong patterns of muscle activity and facial expressions, the pull of gravity on tissue, and diminished elasticity. Spots and lesions are often present on the skin. Smooth, brown, irregularly shaped spots (age spots or senile lentigo) initially appear on the backs of the hands and on forearms. Small, round, red or brown cherry angiomas occur on the trunk. Seborrheic lesions or keratoses appear as irregular, round or oval, brown, watery lesions. Years of sun exposure contribute to the aging of the skin and lead to premalignant and malignant lesions. Rule out these three malignancies related to sun exposure when examining skin lesions: melanoma, basal cell carcinoma, and squamous cell carcinoma.
a
The nurse is completing a health history with the daughter of a newly admitted patient who is confused and agitated. The daughter reports that her mother was diagnosed with Alzheimer's disease 1 year ago but became extremely confused last evening and was hallucinating. She was unable to calm her, and her mother thought she was a stranger. On the basis of this history, the nurse suspects that the patient is experiencing: a Delirium. b Depression. c New-onset dementia. d Worsening dementia.
d
The nurse is completing an admission assessment with an 80-yearold man who experienced a hip fracture following a fall. He is alert, lives alone, and has very poor hygiene. He reports a 20-pound weight loss in the last 6 months following his wife's death, as well as estrangement from his only child. He admits to falls before this most recent fall. What should the nurse suspect? a Dementia. b Elder abuse. c Delirium. d Alcohol abuse.
c
The nurse is working with an older adult after an acute hospitalization. The goal is to help this person be more in touch with time, place, and person. Which intervention will likely be most effective? a Reminiscence b Validation therapy c Reality orientation d Body image interventions
c
The nurse sees a 76-year-old woman in the outpatient clinic. She states that she recently started noticing a glare in the lights at home. Her vision is blurred; and she is unable to play cards with her friends, read, or do her needlework. The nurse suspects that the woman may have: a Presbyopia. b Presbycusis c Cataract(s). d Depression.
hypertrophy
of the prostate gland is frequently seen in older men; urinary retention, frequency, incontinence, and UTIs occur. Prostatic hypertrophy results in difficulty initiating voiding and maintaining a urinary stream. Benign prostatic hypertrophy is different from cancer of the prostate. Cancer of the prostate is the second leading cause of cancer death in American men.
nursing assessment
provides valuable clues to the effects of a disease or illness on a patient's functional status. When you assess older adults, you will need to identify their strengths, weaknesses, and abilities when developing a plan of care.
psychosocial changes
revolve around life transitions and loss. The longer we live, the longer we have to cope with losses. Remember that this group makes up a large part of the U.S. population, as was previously stated. It is important to assess both the nature of the psychosocial changes that occur in older adults as a result of life transitions and the loss and the adaptations to the changes. During your assessment ask how an older adult feels about self, self in relation to others, and self as one who is aging and which coping methods and skills have been beneficial. The psychosocial stresses of retirement are usually related to role changes with a spouse or within the family and to loss of the work role. Preretirement planning is an important advisable task. People who plan in advance for retirement generally have a smoother transition. Retirement also affects the spouse, adult children, and even grandchildren. In the adjustment to retirement an older adult has to develop a personally meaningful schedule and a supportive social network. Factors that influence a retired person's satisfaction with life are health status and sufficient income. Social isolation can occur voluntarily or involuntarily. The nurse assess patients' potential for social isolation by identifying their social network, access to transportation, and willingness and desire to interact with others. Outreach programs are available, including Meals on Wheels, daily telephone calls, and volunteer opportunities. All older adults, whether healthy or frail, need to express their sexual feelings. Sexuality involves love, warmth, sharing, and touching, not just the act of intercourse. Knowing an older adult's sexual needs allows you to incorporate this information into the nursing care plan. Not all nurses feel comfortable counseling older adults about sexual health and intimacy-related needs. Be prepared to refer older adults to an appropriate professional counselor. The extent of an older adult's ability to live independently influences housing choices. The goal of your assessment of a patient's environment is to consider resources that promote independence and functional ability. Assess their activity level, financial status, access to public transportation and community activities, environmental hazards, and support systems. When helping patients consider housing, plan for the future. The environment supports or hinders physical and social functioning, enhances or drains energy, and complements or taxes existing physical changes such as vision and hearing. Furniture needs to be comfortable and safe. Older adults have to deal with the death of family, friends, and their spouse. Nurses need to help them cope with loss. They are concerned with being a burden, experiencing suffering, being alone, and the use of life-prolonging measures. Nurses should have knowledge of the grieving process, excellent communication skills, understanding of legal issues and advance care planning, familiarity with community resources; and awareness of one's own feelings, limitations, and strengths as they relate to care of those confronting death. When assessing these five changes, make sure to also assess older adults' family situation, intimate relationships, past and present occupations, finances, housing, social networks, normal activities, health and wellness, and spirituality.
health promotion and maintenance physiological concerns
To increase the desire for older adults to participate in health promotion, use an individualized approach, taking into account a person's beliefs about the importance of staying healthy and remaining independent. Limitations in ADLs limit the ability to live independently. Most older adults want to remain independent and prevent disability.
heart disease
Treatment of systolic pressures 160 or higher
older adults and restorative care
Types of ongoing care: Continues recovery from acute illness Addresses chronic conditions that affect daily functioning Goal To regain or improve prior level of independence, ADLs, instrumental activities of daily living (IADLs) Both types of restorative care take place in private homes and long-term care settings. Pay attention to the exercise regimen, wound care regimen, medication schedules, vital signs monitoring, and blood glucose monitoring. Include the patient and family members. The aim is to stabilize their condition while promoting health and independence. Restorative nursing interventions stabilize chronic conditions, promote health, and promote independence in basic and instrumental activities of daily living. Beyond the basic ADLs, you need to support an older adult's ability to perform IADLs such as using a telephone, doing laundry, cleaning the home or apartment, and driving an automobile. Restorative care measures focus on activities that allow older adults to remain functional within their living environments. Collaborate with an older adult to establish priorities of care and patient goals, determine expected outcomes, and select appropriate interventions. Thoughtful assessment and planning lead to goals of care that consider the influence of normal aging changes, facilitate an optimal level of comfort and coping, and promote independence in self-care activities.
sensory impairments
When providing care activities have assistive devices
positive attitudes
are based in part on a realistic portrayal of the characteristics and health care needs of older adults. It is critical for you to respect older adults and actively involve them in care decisions and activities. In the past, institutional settings, such as hospitals and nursing centers, often treated older adults as objects rather than independent, dignified people. The time has come for nurses to recognize and address ageism by questioning prevailing negative attitudes and stereotypes and reinforcing the realities of aging as they care for older adults in all care settings.
cerebrovascular accidents
are the fourth leading cause of death in the United States and occur as brain ischemia or brain hemorrhage. Nursing interventions ranges from teaching older adults about risk-reduction strategies to teaching family caregivers the early warning signs of a stroke and ways to support a patient during recovery and rehabilitation.
malignant neoplasms
are the second most common cause of death among older adults. Nurses educate older adults about early detection, treatment, and cancer risk factors. Encourage them to report nonhealing skin lesions, unexpected bleeding, change in bowel habits, nagging cough, lump in breast or another part of body, change in a mole, difficulty swallowing, and unexplained weight loss. Nurses need to carefully distinguish between signs of normal aging and signs of pathological conditions.
neurotransmitters
chemical substances that enhance or inhibit nerve impulse transmission, change with aging as a result of the decrease in neurons. All voluntary reflexes are slower, and individuals often have less of an ability to respond to multiple stimuli. Sleeping difficulties occur.
muscle strength
diminishes in proportion to the decline in muscle mass. Older adults who exercise regularly do not lose as much bone and muscle mass or muscle tone as those who are inactive. Osteoporosis is a major public health threat. Postmenopausal women experience a greater rate of bone demineralization than older men
aging
does not inevitably lead to disability and dependence. Most older people remain functionally independent despite the increasing prevalence of chronic disease.
alcohol abuse
in older adults report two patterns: a lifelong pattern of continuous heavy drinking and a pattern of heavy drinking that begins late in life. The continuum of interventions ranges from simple education about risks to formalized treatment programs that include pharmacotherapy, psychotherapy, and rehabilitation.
hormonal changes
include reduced estrogen and progesterone levels in women, causing vaginal mucosa dryness, irritation and pain with intercourse, and decreased libido for women; ,men typically experience less firm and shorter acting erection, and less forceful ejaculation. Sexual desires, thoughts, and actions continue throughout all decades of life. Less frequent sexual activity often results from illness, death of a sexual partner, or decreased socialization.
abdomen
increases in size due to an increase in the amount of fatty tissue in the trunk. Because muscle tone and elasticity decrease, it also becomes more protuberant. Gastrointestinal function changes include a slowing of peristalsis and alterations in secretions. Alterations in the lower gastrointestinal tract lead to constipation, flatulence, or diarrhea.
cigarette smoking
is a risk factor for the four most common causes of death: heart disease, cancer, lung disease, and stroke. If a patient rejects smoking cessation, suggest at least a reduction in smoking. Set a quit or reduction date and a follow-up visit with the older adult to discuss the quit attempt.
urinary incontinence
is an abnormal and typically embarrassing condition. Stress incontinence is involuntary release of urine that occurs when they cough, laugh, sneeze, or lift an object. This is a result of a weakening of the perineal and bladder muscles. Other types of urinary incontinence are urgency, overflow, functional, and mixed incontinence. The risk factors for urinary incontinence include age, menopause, diabetes, hysterectomy, stroke, and obesity.
heart disease
is the leading cause of death in older adults, followed by cancer, chronic lung disease, and stroke. Common cardiovascular disorders are hypertension and coronary artery disease. Nursing interventions for hypertension and coronary artery disease address weight reduction, exercise, dietary changes, limiting salt and fat intake, stress management, and smoking cessation. Patient teaching also includes information about medication management, blood-pressure monitoring, and the symptoms indicating the need for emergency care
chronic obstructive pulmonary disease
is the third leading cause of death in those 65 and older. Tobacco smoke is a key factor in the development and progression of COPD. It is important to provide patients with information about quit smoking programs. Teach proper exercise, how to use inhalers, techniques for the removal of mucus from the airways, and exercise training.
sexuality
Love, warmth, sharing, intercourse
pain
Maximize function and improve quality of life
falls
Medication use, history, type of shoes, health conditions
therapeutic communication
Meeting clients needs, caring nurse attitudes of concern, kindness, & compassion. skills enable you to perceive and respect the older adult's uniqueness and health care expectations. Attentive nurses provide care in a timely fashion, meeting a patient's expressed or unexpressed needs. A caring nurse expresses attitudes of concern, kindness, and compassion. Knowledgeable nurses not only demonstrate procedural competence but recognize needs and relay information skillfully.
community based and institutional health care services
Nurses encounter older-adult patients in a wide variety of community and institutional health care settings: Private homes, apartments, retirement communities, adult day care centers, assisted-living facilities, and nursing centers Older adults need to help with decisions regarding which type of health care service is appropriate for them. Nurses help older adults and their families by providing information and answering questions as they make choices among care options. Your assistance is especially valuable when patients and families need to make decisions about moving to a nursing center. Some family caregivers consider nursing center placement when in-home care becomes increasingly difficult, or when convalescence (recovery) from hospitalization requires more assistance than the family is able to provide. Although the decision to enter a nursing center is never final, and a nursing center resident is sometimes discharged to home or another less-acute facility, many older adults may view the nursing center as their final residence. The best way to evaluate the quality of a nursing center in a community is for the patient and family to visit that facility and inspect it personally.
nurses attitudes toward older adults
Nurses must assess their own attitude toward older adults and their own aging. Nurses need to gain knowledge about aging and health care needs of older adults: Respect Dignity Involvement in care decision and activities
assessing the needs for older adults
Nursing assessment to ensure an age-specific approach The interrelation between physical and psychosocial aspects of aging Effects of disease and disability on functional status ***Tailoring the nursing assessment to an older person: Allowing for additional time due to longer life and medical history and potential complexity of the history Allow periods of rest Review prescribed and OTC medications Hearing impairment-speak directly to patient, clear and low pitched tones, move to quiet area to reduce background noise Visual impairment-face them at eye level Encourage use of assistive devices; hearing aids/glasses Obtaining a complete assessment takes time; older adults have longer life and medical history. Allow rest periods; be sure to review prescribed and over-the-counter medications. Take into account vision and hearing constraints. If an older adult is unable to understand your visual or auditory cues, your assessment data will likely be inaccurate or misleading, leading you to incorrectly conclude that the older adult is confused. When a person has a hearing impairment, speak directly to the patient in clear, low-pitched tones and move to a quiet area to reduce background noise. When caring for people with visual impairments, sit or stand at eye level and face them. Always encourage the use of assistive devices such as glasses and hearing aids. Memory deficits, if present, affect the accuracy and completeness of your assessment; may need to enlist help of family member or caregiver. The additional person supplements information with the consent of the older adult, but the older adult remains the primary source of the interview. Provide culturally competent care. Must recognize and process your own biases related to ageism, social norms, and racism, as it affects your ability to provide culturally competent care. Remember which changes are related to the aging process and which changes are related to a disease process. It is important to recognize early indicators of acute illness in older adults. Note changes in mental status, occurrence and reason for falls, dehydration, decrease in appetite, loss of function, dizziness, and incontinence because these symptoms are not frequently present in younger adults. Mental status changes commonly occur as a result of disease and psychological issues. Falls are complex and often cause injury. You need to investigate every fall carefully to find out if it was the result of environmental causes or the symptom of a new-onset illness. Problems with the cardiac, respiratory, musculoskeletal, neurological, urological, and sensory body systems sometimes present with a fall as a chief symptom of a new-onset condition. Dehydration is common in older adults because of decreased oral intake related to a reduced thirst response and less free water as a consequence of a decrease in muscle mass. Decrease in appetite is a common symptom with the onset of pneumonia, heart failure, and urinary tract infection (UTI). Thyroid disease, infection, cardiac or pulmonary conditions, metabolic disturbances, and anemia are common causes of functional decline. Nurses play an essential role in early identification, referral, and treatment of health problems.
myths and stereotypes
Older adults are: Ill, disabled, and unattractive Forgetful, confused, rigid, boring, unfriendly, and poor Unable to learn and understand new information Not interested in sex or sexual activities These ideas demonstrate ageism, which is discrimination against people because of increasing age. When health care providers hold negative stereotypes about aging, their actions often negatively affect the quality of patient care. Nursing care of older adults poses special challenges because of great variation in their physiological, cognitive, and psychosocial health. As nurses, you should not be susceptible to myths and stereotypes. Some people equate worth with productivity; therefore they think that older adults become worthless after they leave the workforce. Others consider their knowledge and experience too outdated to have any current value. Ageism typically undermines the self-confidence of older adults, limits their access to care, and distorts caregivers' understanding of the uniqueness of each older adult. Always promote a positive perception regarding the aging process when you establish therapeutic relationships and show respect to older adults. Older adults are a significant proportion of the consumer economy. As voters and activists in various issues, they have a major influence in the formation of public policy. Their participation adds a unique perspective on social, economic, and technological issues because they have experienced almost a century of developments. Even though older adults may be slower and may have troubles with vision, hearing, and dexterity, when you plan care, you will take into account their positive attributes. Although reduced energy and endurance sometimes affect the process of learning, older adults are lifelong learners. Older adults have been through the depression, wars, and changes in health care throughout their lives. Living through all of these events and changes, they have stories and examples of coping with change to share.
d
Older adults frequently experience a change in sexual activity. Which best explains this change? a The need to touch and be touched is decreased. b The sexual preferences of older adults are not as diverse. c Physical changes usually do not affect sexual functioning. d Frequency and opportunities for sexual activity may decline.
physiological changes
Perception of well-being defines quality of life. Older patients' concept of health revolves around how they perceive their ability to function/engagment in activities of daily living usually consider themselves healthy Nurses need to be cognizant of normal age-related changes. Not all physiological changes are pathological Can make more older adults more vulnerable to some common clinical conditions/diseases Normal physiological changes of aging are not pathological processes, but they make older adults more vulnerable to common clinical conditions and diseases. Older adults engaged in activities of daily living (ADLs) usually consider themselves healthy, whereas those who have physical, emotional, or social impairments that limit their activities perceive themselves as ill.
elder mistreatment
Physical, emotional, financial, sexual, neglect & abandonment. Screen privately/mandatory reporting. is defined as "intentional actions that cause harm or create serious risk of harm to a vulnerable elder by a caregiver or other person who is in a trust relationship to the elder." Types of elder mistreatment include physical abuse, emotional abuse, financial exploitation, sexual abuse, neglect (intentional and unintentional), and abandonment. Screen for elder mistreatment and assess for physical and emotional signs of abuse. Complete the interview and assessment privately away from the caregiver. Some states require mandatory reporting.
variability among older adults
Physiological, cognitive, and psychosocial health Levels of functional ability Dependence vs. independence Strengths and abilities
medication use
Polypharmacy; challenging for nurses., increase risk for adverse effects.
smoking
Quitting will reduce coronary heart disease 50%
depression
A mood disturbance characterized by feelings of sadness and despair. is the most common, yet most undetected and untreated, impairment in older adulthood. Suicide in older adults accounts for 20% of all suicides. Treatment includes medication, psychotherapy, or a combination of both. Electroconvulsant therapy (ECT) is sometimes used for treatment of resistant depression when medications and psychotherapy do not help. White men, age 85 and older, have the highest suicide rate in the U.S.
b
A nurse conducted an assessment of a new patient who came to the medical clinic. The patient is 82 years old and has had osteoarthritis for 10 years and diabetes mellitus for 20 years. He is alert but becomes easily distracted during the assessment. He recently moved to a new apartment, and his pet beagle died just 2 months ago. He is most likely experiencing: a Dementia. b Depression. c Delirium. d Hypoglycemic reaction.
b
A nurse is assessing an older adult brought to the emergency department following a fall and wrist fracture. She notes that the patient is very thin and unkempt, has a stage 3 pressure ulcer to her coccyx, and has old bruising to the extremities in addition to her new bruises from the fall. She defers all of the questions to her caregiver son who accompanied her to the hospital. The nurse's next step is to: a Call social services to begin nursing home placement. b Ask the son to step out of the room so she can complete her assessment. c Call adult protective services because you suspect elder mistreatment. d Assess patient's cognitive status.
nursing management of dementia
always considers the safety and physical and psychosocial needs of the older adult and the family. These needs change as the progressive nature of dementia leads to increased cognitive deterioration. To meet the needs of the older adult, individualize nursing care to enhance quality of life and maximize functional performance by improving cognition, mood, and behavior.
most older adults
are active and involved members of their communities. A smaller number have lost the ability to care for themselves, are confused or withdrawn, and/or are unable to make decisions concerning their needs. Most older adults live in noninstitutional settings. However, a smaller number have lost the ability to care for themselves.
health promotion and maintenance
Approximately 80% of adults over 65 have at least one chronic illness. The AOA reports that in 2008 38% of older persons had some type of disability (i.e., difficulty in hearing, vision, cognition, ambulation, self-care, or independent living). Limitations in ADLs limit the ability to live independently. A strong relationship has been noted between disability status and reported health status. Treatment of systolic pressures of 160 mm Hg or higher is linked to reduced incidence of myocardial infarction, stroke, and heart failure. Nurses educate older adults about early detection, treatment, and cancer risk factors. Risk factors for cerebrovascular accidents (CVAs) (stroke) include hypertension, hyperlipidemia, diabetes mellitus, history of transient ischemic attacks, and family history of cardiovascular disease. [Ask students: What do nurses do to effect changes in these risk factors?] Within a year of quitting, former smokers reduce their risk of coronary heart disease by 50%. Suspicion of alcohol abuse increases when there is a history of repeated falls and accidents, social isolation, recurring episodes of memory loss and confusion, failure to meet home and work obligations, a history of skipping meals or medications, and difficulty managing household tasks and finances. Identification and treatment of coexisting depression are important. Good nutrition for older adults includes appropriate caloric intake and limited intake of fat, salt, refined sugars, and alcohol. Help prevent dental and gum disease through education about routine dental care. Regular daily exercise such as walking builds endurance, increases muscle tone, improves joint flexibility, strengthens bones, reduces stress, and contributes to weight loss. Whenever you provide care activities, make sure that the patient is wearing assist devices such as a hearing aid or glasses, so he or she can fully participate in care. (See also Chapter 49.) The goal of nursing management of pain in older adults is to maximize function and improve quality of life. Medication use presents one of the largest challenges for nurses. Older adults can take numerous prescription and over-the-counter medications. Polypharmacy, the concurrent use of many medications, increases the risk for adverse drug effects, inappropriate use of medications, and falls in older adults.
housing and environment
Assess activity level, financial status, transportation, independence and functional ability, environmental hazards
body image interventions
Assist with grooming & hygiene, feelings about self r/t illness, procedures, pain, changes. Some interventions are more crucial for older adults experiencing social isolation; cognitive impairment; or stresses related to retirement, relocation, or approaching death. The way that older adults present themselves influences body image and feelings of isolation. Consequences of illness and aging that threaten an older adult's body image include invasive diagnostic procedures, pain, surgery, loss of sensation in a body part, skin changes, and incontinence. Nurses influence the older adult's appearance by helping with grooming and hygiene.
learning needs
Cognitive and sensory changes are challenges for teaching older adults During assessment, the nurse needs to determine additional needs for teaching and limitations of the older adult in their capability to learn Learn at a slower rate Difficulties processing multiple bits of information at one moment As you assess the various physical, cognitive, functional and psychosocial problems of older adults, it is important to also assess their associated learning needs. If a patient has slow responses or reaction time when performing physical activities, it will be necessary to consider these limitations when teaching new psychomotor skills. Older adults learn new information at a slower rate than younger adults due to a decline in fluid intelligence, which is defined as the reasoning and processing components of learning. In addition, an older adult has difficulty processing multiple bits of information at one moment. During your assessment, carefully consider a patient's learning needs and capability to learn.
death
Coping strategies, grieving/suffering, legal issues
heart and vascular system
Decreased contractile strength of the myocardium results in decreased cardiac output The body tries to compensate for decreased cardiac output by increasing the heart rate during exercise; takes longer for an older adult's rate to return to baseline. Systolic and/or diastolic blood pressures are sometimes abnormally high. Although a common chronic condition, hypertension is not a normal aging change and predisposes older adults to heart failure, stroke, renal failure, coronary heart disease, and peripheral vascular disease. Peripheral pulses frequently are still palpable but weaker in lower extremities. As estrogen production diminishes, the milk ducts of the breasts are replaced by fat, making breast tissue less firm. Decreased muscle mass, tone, and elasticity result in smaller breasts in older women. In addition, the breasts sag. Gynecomastia, enlarged breasts in men, is often the result of medication side effects, hormonal changes, or obesity. Both older men and women are at risk of breast cancer.
b, d
During a home health visit a nurse talks with a patient and his family caregiver about the patient's medications. The patient has hypertension and renal disease. Which of the following findings place him at risk for an adverse drug event? (Select all that apply.) a Taking two medications for hypertension b Taking a total of eight different medications during the day c Having one physician who reviews all medications d Patient's health history of renal disease e Involvement of the caregiver in helping with medication administration
cancer
Educate early detection treatment and risk factors
dental problems
Educate routine dental care
head and neck
Facial features Visual acuity Auditory changes Salivary secretion The facial features of an older adult sometimes become more pronounced from loss of subcutaneous fat and skin elasticity; appear asymmetrical because of missing teeth or improperly fitting dentures. Visual acuity declines with age. This is often the result of retinal damage, reduced pupil size, development of opacities in the lens, or loss of lens elasticity. Presbyopia, is common. Glare effects increase. Pupils are smaller and react slower. Difficulty with going from bright to dark environments. Changes in color vision makes it difficult to distinguish between blue and green. Diseases include cataract, macular degeneration, diabetic retinopathy, and retinal detachment. Auditory changes are often subtle. Common change is presbycusis, which affects the ability to hear high-pitched sounds and conversational speech and is typically bilateral, affecting more men than women. Inspect the external auditory canal for the presence of cerumen. Salivary secretion is reduced, and taste buds atrophy and lose sensitivity. Health conditions, treatments, and/or medications often alter taste. It is often a challenge to promote optimal nutrition in an older patient because of the loss of smell and changes in taste.
functional changes
Functional status in older adults includes the day-to-day activities of daily living (ADLs) involving activities within physical, psychological, cognitive, and social domains. Changes are usually linked to illness or to disease and degree of chronicity. Performance of ADLs is a sensitive indicator of health or illness. Occupational and physical therapists are your best resources for a comprehensive assessment. The fear of becoming dependent is overwhelming for an older adult who is experiencing functional decline as a result of aging. Educate older adults to promote understanding of age-related changes, appropriate lifestyle adjustments, and effective coping. Factors that promote the highest level of function include a healthy, well-balanced diet; paced and appropriate activity; regularly scheduled visits with a health care provider; regular participation in meaningful activities; use of stress-management techniques; and avoidance of alcohol, tobacco, or illicit drugs. It may be difficult for older adults to accept the changes that are occurring in all areas of their lives, which in turn have a profound effect on functional status. Several standardized functional assessment tools are widely available. A sudden change in function with ADLs is often a sign of onset of an acute illness or worsening of a chronic illness. When planning and implementing care for older adults, you will want to develop interventions aimed at maintaining, restoring, or maximizing their functional status, while maintaining independence and preserving dignity. lts to accept the changes that are occurring in all areas of their lives, which in turn have a profound effect on functional status.
dementia
Generalized impairment of intellectual functioning not curable. is characterized by a gradual, progressive, irreversible cerebral dysfunction. It interferes with social and occupational activities and is an umbrella term for many conditions, including Alzheimer's. Assess carefully to rule out the presence of delirium whenever you suspect dementia. Nurses should consider the safety and physical and psychosocial needs of the older adult and the family. Individualize nursing care to enhance quality of life and maximize functional performance by improving cognition, mood, and behavior.
addressing health concerns of older adults
Healthy People 2020 goals: Increase the number of older adults with one or more chronic conditions who report confidence in maintaining their conditions. Reduce the proportion of older adults who have moderate-to-severe functional limitations. Increase the proportion of older adults with reduced physical or cognitive function who engage in light, moderate, or vigorous leisure-term physical activities. As the population ages and life expectancy increases, emphasis on health promotion and disease prevention increases. The challenges of health promotion and disease prevention for older adults are complex and affect health care providers as well. Previous health care experiences, personal motivation, health beliefs, culture, health literacy, and non-health-related factors such as transportation and finances often create barriers for older adults. Barriers for health care providers include beliefs and attitudes about which services and programs to provide, their effectiveness and the lack of consistent guidelines, and absence of a coordinated approach. ****The nurse's role is to focus interventions on maintaining and promoting patients' function and quality of life. You can empower older adults to make their own health care decisions and realize their optimum level of health, function, and quality of life.
alcohol abuse
Hx of falls, memory loss & confusion, skipping meals and meds, may have depression
stroke
Hypertension, diabetes, hyperlipidemia (fat in blood stream)
social isolation
Identify social network, access to transportation, interact with others
educating older adults
Inadequate health literacy disproportionately affects older adults in the United States, causing misunderstanding of health information and subsequent nonadherence. Nurses must use more than words when teaching older adults Assist in selecting, understanding, and using health-related information about medications The World Health Organization (2015) defines health literacy as the cognitive and social skills that determine the motivation and ability of individuals to gain access to, understand, and use information in ways that promote and maintain good health. A nurse must know how to adapt routine patient education strategies to effectively meet the specific learning needs of elderly patients. Retrieving prescriptions and referrals, selecting providers from a list of names and addresses, calculating when to take multiple medications, interpreting medical terminology, comparing different insurance plans, and sifting through the myriad of health-related information available in magazines, on the Internet, and on television are just a few of the complex thought processes involved in selecting, understanding, and using health-related information about medications
addressing health concerns
Increase the proportion of older adults who receive diabetes self-management benefits. Increase the proportion of the health care workforce with geriatric certification. The nurse's role is to focus interventions on maintaining and promoting patients' function and quality of life.
physical and psychosocial aspects
of aging are closely related. A reduced ability to respond to stress, the experience of multiple losses, and the physical changes associated with normal aging combine to place people at high risk for illness and functional deterioration. Do not assume that all older adults have signs, symptoms, or behaviors representing disease and decline or that these are the only factors you need to assess. You also need to identify an older adult's strengths and abilities during the assessment and encourage independence as an integral part of your plan of care
older adults and the acute care setting
settings pose risks for adverse events: Delirium Dehydration Malnutrition Health care-associated infections Urinary incontinence Falls Pay special attention to the basic needs of comfort, safety, nutrition/hydration, and skin integrity. To promote independence and a sense of dignity, you need to include the patient in his or her care. However, you also need to be firm with these patients to ensure that their basic needs are met, and that no decline in their health status occurs owing to hospitalization. The risk for delirium increases when hospitalized older adults experience immobilization, sleep deprivation, infection, dehydration, pain, sensory impairment, drug interactions, anesthesia, and hypoxia. Older adults are at greater risk for dehydration and malnutrition during hospitalization because of standard procedures such as limiting food and fluids in preparation for diagnostic tests and medications that decrease appetite. Increased risk for health care-associated infections in older adults is associated with age-related reductions in immune system responses. Causes of incontinence include delirium, untreated urinary tract infection, medications, restricted mobility or need for assistance to get to the bathroom, and constipation or stool impaction. The increased risk for skin breakdown and the development of pressure ulcers is related to changes in aging skin and to situations that occur in the acute care setting such as immobility, incontinence, and malnutrition The cause of a fall is typically multifactorial and composed of intrinsic or extrinsic factors.
