Ch. 32 Assessing Older Adults

The nurse is reviewing the results of laboratory blood tests with the older adult. The client asks, "Why is my creatinine elevated?" Which is the best response by the nurse?

*"As a person gets older, the kidneys do not work as well in removing waste materials."* The size and function of the kidneys decrease with age. Consequently, the kidneys do not work as well in removing waste materials. The glomerular filtration rate is decreased and is reflected in a decrease in urinary creatinine clearance and increased serum creatinine. While the response, "Creatinine is an indicator of how well the kidneys are functioning in removing wastes." is correct, it does not explain to the client why the level may be elevated

The nurse is assessing a new client, age 68 years, for orthostatic hypotension. The nurse would know that this means a drop in systolic blood pressure of 20 mm Hg or more or diastolic blood pressure of 10 mm Hg or more within how many minutes of standing?

*3 minutes*

To reduce the risk for late recognition of cognitive impairment in the older adult client, which actions should the nurse take? Select all that apply.

*Adopt more direct questions. Use geriatric screening tools. Consult family members or caregivers.* Older adult clients may be reluctant to report their symptoms or overlook them believing that they are a normal part of aging. To reduce the risk for late recognition and delayed intervention of any health problem in the older adult client, it is important to adopt direct questions, use geriatric screening tools, and consult family members or caregivers. Normalizing forgetfulness encourages under-reporting of symptoms and may prevent the older adult client from offering more detailed information about the memory loss. Teaching about sexual health would not be an appropriate action to take when reducing the risk for late recognition of cognitive impairment.

The nurse observes several patchy white areas on the scalp of an older adult client. What is the nurse's best action?

*Apply prescribed steroid cream* Patchy white scaly areas on the scalp or eyebrows are indicative of seborrhea, common in persons with Parkinson disease and usually treated with topical corticosteroids. Bruises in various stages of healing might indicate abuse. Pressure ulcers are staged, not seborrhea.

The nurse observes the gait and stature of an elderly client entering the room. Which of the following findings is an age-related change?

*Arms appear long in proportion to the trunk.* Vertebral compression fracture and intervertebral disc compression contribute to the kyphosis of aging and increased anteroposterior diameter of the chest, especially in women. For these reasons, the limbs of an elderly person tend to look long in proportion to the trunk. A wide-based gait, asymmetry between the height of the shoulders, and knee flexion throughout the stance phase would be indicators of health problems.

The nursing assistant informs the nurse of an older adult client's vital signs: Blood pressure 130/78; Pulse 60; Respirations 16; Temperature 98.7 degrees Fahrenheit. What is the nurse's best action?

*Check the client's mental status.* Temperatures within expected range for a younger adult may constitute fever in an older adult. Since the client may be suffering from fever due to a possible infection, the nurse should assess mental status. Confusion and changes in mental status are often first signs of infection in older adults. The remaining vital signs are within normal limits and do not require intervention.

The nurse is assessing an elderly client and finds a suspicious lesion on the client's right forearm. The lesion is asymmetrical, has an irregular border, has color variation, and is approximately 8 mm in diameter. What is an appropriate nursing action for this client?

*Document findings and refer the client for follow-up*

An older client exhibits a strong dorsalis pedis pulse in the right foot and a weak dorsalis pedis pulse in the left foot. How should the nurse document these findings?

*Dorsalis pedis pulses are 1+ left and 2+ right.* Peripheral pulses are documented on a 4 point scale. 1+ = weak; 2+-3+ = strong; 4+ = bounding pulse.

Blood pressure abnormalities found more commonly in Western elderly include which of the following?

*Elevation of the systolic BP* Isolated systolic hypertension is common in the elderly because of stiffening of the large arteries. This is often accompanied by widening of the pulse pressure. Orthostatic BP changes are often seen with postural changes and can account for falls as well.

A nurse obtains an order to check an elderly client for orthostatic hypotension. Which finding alerts the nurse to a positive result for this test?

*Heart rate increases 20 beats over the baseline rate* Orthostatic hypotension is assessed by taking the client's blood pressure lying, sitting, and standing and watching for a drop in the systolic or diastolic pressure of more than 10mmHg or an increase in the heart rate of more than 20 beats or more per minute. A positive test places the client at risk for falls.

The caretaker of an elderly person tells the nurse that she is worried that the client will choke because of swallowing problems secondary to a recent cerebrovascular accident (CVA). What suggestion should the nurse give the caretaker to minimize the risk of aspiration in the client?

*Prepare foods that are pudding consistency or semisolid* The nurse should suggest that the caretaker prepare semisolid foods and fluids of pudding consistency, alternating solid food with thickened foods, and encouraging the client to lean slightly forward and tuck the chin under to prevent gagging. Water and other thin liquids increase the risks of aspiration. Checking the mouth does not help to avoid aspiration. Keeping the client upright will help to prevent acid reflex but not aspiration.

During the skin assessment of an elderly client, a nurse recognizes that which skin condition is a normal finding?

*Senile purpura*

An older adult client is admitted to the hospital for further investigation of abdominal pain. The nurse should consider which risk factor for drug reactions?

*The client has a raised white blood cell count.* With a raised white blood cell count there is likely the presence of infection. The client is going to require antibiotics which can have a high potential for adverse reactions or interactions with other drugs. Age is only a risk factor for drug reactions in clients 80 years or older. Eight different types of medication need to be taken in order for the client to be considered at risk for a drug reaction. A previous history of drug reaction predicts that such as problem will happen again. If the client has no previous history of drug reactions, this would not be a risk factor.

The nurse is assessing an older adult client who lives alone and was brought to the clinic by the client's grandson. The client's hair is messy, clothes are very dirty, and the client has very bad body odor. What do these signs most likely indicate to the nurse?

*The client has decreased functional ability* Poor hygiene and inappropriate dress in an older adult may indicate decreased functional ability or may result from medications, infection, dehydration, or nutritional status. Inappropriate affect, inattentiveness, impaired memory, and inability to perform ADLs may indicate dementia from Alzheimer's disease or another cause. The information in the scenario does not indicate that the client is lazy; more investigation would be needed before the nurse would suspect neglect or abuse, as would the client's need to reside in a nursing home.

When assessing the skin, hair, and nails of the older adult, the nurse needs to know the normal effects of aging on these structures. Which of the following are normal effects of aging on the integumentary system? Select all that apply.

*The epidermis thins Nails become thick and brittle with slow growth Wound healing slows as a result of decreased mitotic activity* The epidermis thins with aging, and the epithelium renews itself every 30 days instead of every 20 days as in children and adults. This decreased mitotic activity of cells leads to a 50% reduction in rate of wound healing. In addition, there are degeneration of the elastic fibers providing dermal support, a loss of collagen, and a loss of subcutaneous fat. The number of sweat and sebaceous glands decreases as a result of atrophy, and vascularity and capillary fragility of the skin layer are diminished. Nail beds become more rigid, thick, and brittle, with slowed growth.

An elderly client is complaining of weakness and fatigue. The nurse suspects the client may be experiencing what?

*anemia* Anemia must be ruled out when an older client complains of weakness and fatigue. Weakness and fatigue is not part of the normal aging process. Cancer may include many symptoms. A symptom of depression may include fatigue, but not weakness.

When assessing an older adult, the nurse finds the client has a history of falls, shortness breath and fatigue. The nurse would suspect the client is experiencing what?

*cardiac dysrhythmias*

A gastrointestinal problem that often requires emergency treatment in the frail elder is

*diverticulitis* If diverticula become infected, emergency treatment may be required to prevent perforation and sepsis.

During the assessment of an older client the nurse focuses on household activities and home environment. On which geriatric syndrome is the nurse focusing during this assessment?

*fall risk* A geriatric syndrome represents serious issues for older adults and is often related to functional decline. Geriatric syndromes impact quality of life. Household activities and home environment would assess the geriatric syndrome of fall risk. Assessing eating or feeding would determine nutritional status. Assessing continence and mentation would help determine independence. Mobility and nutritional intake would help determine skin status.

Which intervention by the nurse demonstrates the correct technique to assess urinary incontinence?

*obtain a voiding diary* The most appropriate method of assessing urinary incontinence in an elderly client is by obtaining a voiding diary. Inspecting the urethral meatus and vaginal opening helps in assessment of external genitalia. Asking the client to bear down helps in assessment of uterine, vaginal, and rectal prolapse

The nurse is assessing an elderly client that has been hospitalized with weakness. The nurse identifies that what disease is most likely to occur in an elderly hospitalized client?

*pneumonia*

A client is brought to the clinic by his daughter, who tells the nurse that she is concerned because her father appears to be losing weight and she doesn't know why. What would the nurse know is a cause of undernutrition?

*poverty* Low weight is a key indicator of poor nutrition. Undernutrition is seen with depression, alcoholism, cognitive impairment, malignancy, chronic organ failure (cardiac, renal, pulmonary), medication use, social isolation, and poverty.

During the breast exam of an elderly female client, which finding should a nurse recognize as a normal change associated with the aging process?

*retraction of the nipples* Nipples retract in the elderly client due to loss of musculature. Unlike nipple retraction due to a mass, nipples retracted due to aging can be everted with gentle pressure. Macerated ski under the breasts may be due to perspiration or a fungal infection. Bilateral tenderness may be seen in women on hormone replacement therapy and indicate that the dose needs to be lowered. Nipple discharge is only normal in breast feeding women.

The nurse observes a dark brown, pigmented waxy lesion 2-mm in size on the right forearm of an older adult. The nurse recognizes this lesion as:

*seborrheic keratosis* Seborrheic keratosis is a dark brown, pigmented waxy lesion. Basal cell carcinoma starts as a small smooth, hemispherical translucent papule covered by a thinned epidermis, usually on the face. The papule gradually enlarges into a pearly nodule with a ulcerated center. Squamous cell carcinoma starts as a hard, red, wart-like lesion with a raised or rolled gray yellow edged found on highly sun-exposed areas. Malignant carcinoma is a variegated pigmented macule, papule, nodule, patches, or tumor, usually asymmetric with an irregular border and greater than 6 mm in

For which reason should the nurse use the 10-minute screener when assessing the older adult client?

*to evaluate age-related changes that support optimal functioning* The 10-minute geriatric screener evaluates for age-related changes that help older adults maintain optimal functioning. It covers the three important domains of geriatric assessment: physical, cognitive, and psycho-social function. The SPICES mnemonic focuses on frequent geriatric syndromes of the older adult. This assessment includes a focus on sleep disorders, problems with eating, incontinence, confusion, evidence of falls, and skin breakdown. The ETHICS mnemonic helps clinicians escape the pitfalls of group labeling by expanding the individual history taking to include the explanation, treatment, healers, negotiate, intervention, collaborate, and spirituality. The 10-minute screener is not structured to assess for activities of daily living.