Exam 2

Summary of sexuality

-Appreciate that older adults often maintain sexual interest and activity late into life Menopause in women Andropause in men Ability to engage in sexual activity is not lost with age, but other factors can affect this Such as: -Health conditions -lack of partner

Ethical terms to know

Autonomy To respect individual freedoms, preferences, and rights Beneficence To do good for patients Confidentiality To respect the privacy Ethics A system of moral principles that guides behaviors Fidelity To respect our words and duty to patients Justice To be fair, treat people equally Nonmaleficence To prevent harm to patients Veracity Truthfulness

Poor nutritional intake at end-of-life

Causes: -Anorexia, nausea, vomiting prevent adequate nutritional intake -Fatigue and weakness (if patient is on cancer, if you feed them, you feed the cancer. so everything that goes in just feeds the cancer) Interventions: Stimulation of appetite if appropriate -Serving small-portioned meals that have alluring appearances and aromas -Providing patient's favorite foods -An alcoholic drink before meals can boost appetite of some Antiemetics, antihistamines; ginger -Controls nausea and vomiting -Ginger is natural antiemetic Ginger has been effective in controlling nausea for some individuals without the side effects of antiemetic drugs Other basic nursing measures -Oral hygiene -Clean, pleasant environment for dining -Pleasant company during mealtime -Assist with feeding as necessary

Respiratory introduction

Effects of aging on respiratory system = maximum function gradually declines -If someone is unable to breathe, this will affect the person physically, mentally, and socially. Respiratory diseases: -Leading cause of disability -Fourth leading cause of death

Realities of Sex

Lack of research and information Acceptance and expansion of sexology just within past few decades Open discussions about sex was viewed as uncomfortable, rude, or improper Misconceptions -Misconception that older individuals are neither interest in nor capable of sex Practitioners lack experience with discussion -Nor did they desire to discuss sex with ANY age group Practitioners don't want to discuss sex Today lack of inquiry into sexual history or activity continues -Medical and nursing assessments frequently do not reflect inquiry into sexual history and activity

Alternatives to Drugs

Lifestyle changes -Diet modifications -Regular exercise -Stress management -Regular schedule for sleep and rest, and elimination Alternative and complementary therapies -May replace drugs or allow lower dosages to be utilized

What is your (legal) responsibility as a nurse?

Nurse must know basic laws and confirm their practice falls within sound boundaries (scope of practice = boundaries) 1. Gerontological nurses function in autonomous roles 2. They supervise unlicensed personnel and accountable for their actions 3. Problems faced by older adults may lead to legal issues 4. Nurses need to advocate for older adult rights

More healthy sexual function

Consideration for institutionalized older adults Masturbation --> provide privacy + nonjudgmental attitude Holding, caressing, and exchanging loving words as a means for sexual satisfaction Recognize, respect, and encourage sexuality in older adults

Skin issues affecting appearance

Efforts to avoid normal outcomes of aging can be fruitless and frustrating to clarify -Money that could be applied to more basic needs is sometimes invested in attempts to defy reality Clarify misconceptions -Emphasize that no cream, lotion, or miracle drug will remove wrinkles and lines or return youthful skin -encourage use of cosmetics to protect the skin and maintain an attractive appearance Informed about cosmetic surgery -be informed of various types of surgical interventions -help locate competent cosmetic surgeons Assess reasons for seeking cosmetic surgery -rational decision rather than symptom of an underlying problem (depression or neurotic disorder) -Counseling and therapy may be more pressing need than surgical intervention

Hypertension (Cardiovascular)

Incidence increases with age Most prevalent cardiovascular disease of older adults Evaluation of blood pressure -Systolic blood pressure over 140 -Diastolic blood pressure over 90 Factors to consider when monitoring blood pressure -Anxiety -Stress -Activity before BP measurement Signs and symptoms Usually no s/s but if EXTREMELY ELEVATED: -Possibly dull headache -Impaired memory -Disorientation -Confusion -Epistaxis -Slow tremor Treatment -Lifestyle changes/nonpharmacologic measures Potential for dangerous decrease in blood pressure with aggressive antihypertensive therapy Drugs used to treat hypertension in older adults Left untreated, can lead to stroke, heart disease, eye problems, kidney failure, and other health problems

Fire hazards

Increased risk for burn injuries due to common home hazards Unattended cooking in kitchen, scald burns -Staying in kitchen while cooking -Setting timer to remind them to check the pot Careless disposal of matches, cigarette burns -Restricting smoking to specific locations and times of the day Falling asleep while smoking -Restricting smoking to specific locations and times of the day Space heaters -Space heaters should have automatic shutoff mechanism to prevent fire if heater is knocked over or falls and intact electrical cords Overloading outlets -Don't use outlets that are overloaded Poor maintenance in fireplace chimney -Need to clean wood-burning fireplaces to prevent chimney blockage Prevention: -Staying in kitchen while cooking -Setting timer to remind them to check the pot -Using a microwave to heat liquids -Restricting smoking to specific locations and times of the day -Inspection of heater is beneficial in assuring safety -Space heaters should have automatic shutoff mechanism to prevent fire if heater is knocked over or falls and intact electrical cords -Need to clean wood-burning fireplaces to prevent chimney blockage

Lung Cancer (Restrictive Pulmonary Disease)

Lung cancer is leading cause of cancer deaths among men and women -Each year, more people die of lung cancer than colon, breast, and prostate cancers combined Incidence -Lung cancer is 2nd most common cancer type in both men and women (In men, prostate cancer is more common. In women, breast cancer) -Smokers have 2X greater incidence than nonsmokers -Older age + highest among black males -Rare in adults younger than 44 yo (< 2%) but increases in incidence between ages 60 and 70 yo. -About 2 out of 3 diagnosed with lung cancer are 65 or older -Average age at diagnosis is 70 years -Lung cancer is more frequent in men in general than in women, and black men are about 20% more likely to develop lung cancer than white men Diagnosis -May go undiagnosed in early stage; often found on routine chest X-ray or CT -Physical exam -Sputum cytology -Lung tissue biopsy -If diagnosed in early stages, there is greater chance of survival Symptoms Nonspecific early on: -Cough (chronic, recurrent) -Fatigue -Weight loss -SOB or wheezing -Coughing up phlegm that contains blood -Chest pain -Anorexia -Wheezing -Recurrent URI -Dyspnea

Summary of cardiovascular

What is the first step the nurse should take when evaluating the patient's circulation in the extremities? -FIRST STEP IS ASSESSMENT -So collect heath history, subjective data, THEN inspect the legs -Assessing for circulation to the lower extremities should begin with a health history and then focus on inspect of the lower extremities Physiologic changes -Decreased stress response -Stiffer valves -Conductivity altered -Vessels less elastic Expected signs or symptoms -Diminished cardiac output -Diastolic murmurs -More ectopic beats; less ability to respond to changes in blood pressure -Poorer perfusion to vital organs with resulting hypoxia; varicosities; peripheral pulses not always palpable

How does the code of ethics affect the nurse practice act?

-Violations of the code of ethics can result in discipline action against the nurse The code of ethics can also ASSIST In protection from regulatory discipline

Cancer prevention

Avoid tobacco use Be physically active Maintain a healthy weight Eat a healthy diet Limit alcohol Limit number of sexual partners and use condoms Get appropriate screening tests Avoid excess sun exposure

Which actions best describes the ethical principle of veracity? A. Preventing a medication error from occurring B. Telling a patient bad news in a honest and truthful manner C. Making a health-related decision for an older adult D. Treating each patient equally while providing care

B. Telling a patient bad news in a honest and truthful manner Veracity is truthfulness. This principle is central to all nurse-patient interactions because the quality of the relationship depends on trust and integrity

Temperature (safety)

Body temperature has an effect on tactile sensitivity, vigilance performance, and psychomotor tasks -These all become impaired in temperatures below 55 degrees F Older adults have lower than normal body temperatures -Less insulation Maintaining adequate environmental temperature is significant Recommended room temperature is 75 degrees F -Less than 70 degrees F can cause hypothermia -Brain damage can result from temperatures exceeding 106 degrees F -Persons with diabetes or cerebral atherosclerosis are at high risk for becoming hyperthermic

Legal safeguards for nurses

Common sense is best ally! Nurses should protect themselves by: -Familiarize with laws and rules governing specific care agency/facility, state's nurse practice act, and labor relations -Become knowledgeable about agency's policies and procedures and adhere to them strictly -Function within scope of practice -Determine for themselves the competency of employees for whom they are responsible -Check the work of employees under their supervision -Obtain administrative or legal guidance when in doubt about legal ramifications of situation -Report and document any unusual occurrence -Refuse to work under circumstances that create a risk to safe patient care -Carry liability insurance

Nursing interventions for good nutrition and hydration

Resources to enhance nutritional status -Food stamps -Meals on wheels -Shopping and meal preparation assistance -Congregate eating programs -Nutritional and psychological counseling -Consider ethnic and religious factors MyPlate for Older Adults -Choose fiber rich foods often -Drink water and other beverages that are low in added sugars -Use fortified foods or supplements to meet vitamin D and vitamin B12 needs

Legal risks in Gero Nursing

What are some situations that may increase the risk of liability? -Working with insufficient resources -Not following agency policies and procedures -Bending rules -Taking shortcuts -Working when physically/emotionally exhausted Big thing is staffing! If you didn't know that the facility you were working for has a policy for X and you do that, it is not a defense! What are acts that could result in legal liability? -Assault (a threat) -Battery (unconsented touching; might be following through with assault; EX: Performing a procedure without consent) -Defamation of character (oral or written communication to third party that damages a person's reputation; Libel is written and slander is spoken; Defamation does not exist if the statement is true) -False imprisonment (unlawful restraint or detention of a person. EX: Preventing a patient from leaving a facility. ACTUAL physical restraint does not need to be used for false imprisonment to occur; TELLING a patient that she will be tied to the bed if she tries to leave will be considered false imprisonment) -Fraud (willful and intentional misrepresentation that could cause harm or cause a loss to a person or property; EX: Selling a patient a ring with the claim that memory will be improved when it is worn) -Invasion of privacy (invading right of an individual to personal privacy. Can include unwanted publicity, releasing medical record, giving patient information to an improper source, or having one's private affairs made public; EX: Allowing a visiting student to look at a patient's pressure ulcers without permission can be an invasion of privacy) -Larceny (unlawful taking of another person's possession; EX: Assuming that a patient will not be using his or her personally owned wheelchair anymore and giving it away to another patient without permission) -Negligence (omission or commission of an act that departs from acceptable and reasonable standards, which can take several forms)

What is the role of the State Board of Nursing?

-Regulate nursing practice and licensure -Protect the public -Define Scope of Practice via Nurse Practice Act

Promoting Healthy Sexual Function

Basic education to understand effects of aging process on sexuality Realistic framework for sexual function RNs willingness to openly discuss sex Sexual history as part of nursing assessment Identification of problems and potential solutions for these problems, or referral

Pneumonia (respiratory health problem)

A leading cause of death in elderly Causes: -Poor chest expansion and more shallow breathing due to age-related changes of respiratory system -High prevalence of respiratory diseases that promote mucus formation and bronchial obstruction -Lower resistance to infection -Reduced pharyngeal reflexes (promotes aspiration of foreign material) -Greater risk of aspiration -Reduced mobility/debilitation -Greater risk for nosocomial pneumonia if hospitalized Common sign: -Confusion/ Change in their mental capacity Presents with: -Slight cough, dry, nonproductive cough -Fatigue -Rapid respiration -Decreased appetite -Decreased functioning -USUALLY NO CHEST PAIN & NO HIGH FEVER (OR MINIMAL FEVER) Frequently, older adults do not experience chest pain or exhibit a high fever as younger adults do -They have a normal lower body temp In older adults, the average body temperature is lower than 98.6°F Pneumococcal vaccine (PPSV23) recommended for age 65+ -PCP MAY consider PCV13 if client has never received before and meet criteria Can also develop complication of paralytic ileus, which can be prevented by mobility KEY CONCEPT: -Productive cough, fever, and chest pain may be atypical in older adults because of age-related changes, which may cause a delayed diagnosis of pneumonia

Promotion of oral health

Ability to meet nutritional needs is influenced by dental care throughout lifetime -Poor dental care, environmental influences, inappropriate nutrition, and changes in gingival tissue commonly contribute to severe tooth loss Periodontal disease as the cause of tooth loss -After third decade of life, periodontal disease becomes first cause of tooth loss Review signs of periodontal disease -Bleeding gums, particularly when teeth are brushed -Red, swollen, painful gums -Pus at gum line when pressure is exerted -Chronic bad breath -Loosening of teeth from gum line Denture use and the continued need for dental care -Use of toothbrush is more effective than swabs or other soft devices in improving gingival tissues and removing soft debris from teeth -Lemon-glycerin swabs (contain citric acid) dry oral mucosa and contribute to tooth enamel erosion) -Mouthwashes with high alcohol content can be too harsh for older mouths -Diluting commercial mouthwash with water (half and half) is recommended -Care should be taken to not traumatize tissues when performing oral hygiene -Loose teeth should be extracted to prevent from being aspirated and causing lung abscess Dentures -Many old people believe dentures eliminates need for dental care Lesions, infections, and other diseases can be detected by dentist and corrected to prevent serious complications -Changes in tissue structure may affect fit of dental appliances -Poorly fitting dentures need not always be replaced (they can be lined to ensure proper fit) Dental appliances should be used and not kept in pocket or dresser drawer! -Wearing dental appliances allows proper chewing, encouraging older people to introduce a wider variety of foods into diets

Advanced Directives

Advance directives express patient desires for terminal care and life-sustaining measures and other issues pertaining to dying and death Following advance directive protects health care professionals from civil and criminal liability when they are followed in good faith Patient Self-Determination Act requires health care facilities to ask a patient about advance directives -Requires all health institutions receiving Medicare or Medicaid funds to ask patients on admission if they possess a living will or durable power of attorney for health care -Patient's response must be recorded in the medical record -Nurses can make physicians and other staff aware of the presence of patient's advance directive -Inform patients of any special measures they must take to have the document accepted into medical record and follow the patients wishes States vary in use and types of advance directives; durable power of attorney for health care, living will -RN can't pronounce death in Texas -In Hospice, you can pronounce death. 2 types of advance directives: 1. Durable power of attorney for health care -Document that appoints a person selected by the patient to make decisions on patient's behalf should patient be unable to make or communicate his or her decisions 2. A living will -Describes patient's preferences and gives instructions to health care providers if at a future time he or she is unable to make or communicate decisions and has no one appointed as proxy Wills -Wills are statements of individuals' desires for the management of their affairs after their death -For will to be valid, person making it must be of sound mind and legal age and must not be coerced or influenced into making it -Will should be written, signed, dated, and witnessed by persons not named in the will -Required number of witnesses vary among states Nurses should not be the legal witness to a will -To avoid problems such as family accusations that the patient was influenced by the nurse -Nurses should help patients obtain legal counsel when they wish to execute or change a will -Legal aid agencies and local schools of law are sources of assistance for adults wishing to write their wills If patient is dying and wishes to dictate a will to the nurse, the nurse may write it exactly as stated, sign, and date it; have the patient sign it if possible; and forward it to the agency's administrative offices for handling. Useful for nurses to encourage people of all ages to develop a will to avoid having the state determine how their property will be distributed in event of their death Pronouncement of death falls within the scope of medical, not nursing, practice in several states -Safeguard license by holding physicians responsible for the pronouncement of death Consent for autopsy must be obtained, except in cases of criminal act, malpractice, or occupational disease -Death may be considered a medical examiner's case and an autopsy may be mandatory -Unless it is a medical examiner's case, consent for autopsy must be obtained from the next of kin, usually in order of: spouse, children, parents, siblings, grandparents, aunts, uncles, and cousins

Increased Risk of Adverse Reactions

Adverse drug reactions are leading cause of morbidity and mortality in US. -Unexpected and undesirable response to drug Risk of adverse drug reactions is higher in older adults related to altered pharmacokinetics and pharmacodynamics Mental dysfunction is often an early sign with many medications -Need to assess all potential etiologies for changes in mental status -Ensure that drug-induced cognitive and behavioral problems are not treated with additional drugs!! General factors when assessing: -S/S Of an adverse reaction to a given drug may differ in older people -A prolonged time may be required for an adverse reaction to become apparent in older people -An adverse reaction to a drug may be demonstrated even after the drug has been discontinued -Adverse reactions can develop suddenly, even with a drug that has been used over a long period of time without problems Causes: -Ingesting wrong dosage -Incorrect time -Stopping drug too early -Not taking appropriate dose -Prescribing drug inappropriately

Supporting the dying individual

Allow and accept HOPE! Commonly permeates all stages -Used as temporary form of denial -Rationalization for unpleasant therapies -Source of motivation A realistic confrontation of impending death does not negate the presence of hope Rational Suicide and Assisted Suicide Growing acceptance Rational suicide Competent adult makes reasoned decision to die by suicide while cognitively intact and relatively free from pain Assisted suicide -Individual has decided to end his or her life and does so with the aid of another person -Legal in some states (CA, CO, OR, VT, WA) -May be assisted by medical professional (who may advise person about lethal doses of drugs or may supply these drugs) Should explore reasons before accepting suicide plans - "Why are you making this choice?" -"What concerns do you have?" -"Do you have plans for carrying this out?" -"Is there someone who has agreed to help you carry this out?"

Laws governing Gero Nursing practice

Are laws the same in every state? -- NO! There are variation among states. What does public law cover? -private/government relationships -Criminal law; practice regulations -Scope of nursing practice -Requirements for licensure What does private law cover? -Individual rights: private law protects an individual's rights and sets standards of conduct -Standards of conduct: involves torts (a wrongful act or an infringement of a right (other than under contract). Examples include assault, battery, etc.) and contracts What's an example of voluntary standards? Basic competencies for nurses Voluntary standards adopted by ANA Voluntary standards are developed and implemented by the nursing profession itself. They are not mandatory but are used as guidelines for peer review. The organizations that set standards are guided by society's need for nursing and by the public's expectations of nursing

Special dietary needs of women

At-risk nutrition related conditions affecting women: Heart disease -reduction of fat intake to 30% kcal or less can be beneficial in reducing risk Cancer -Low-fat intake in reduced risk of breast cancer -Reduce alcohol consumption; daily intake of 40 g or more linked to increased risk of breast cancer Osteoporosis -Nearly all women affected by some degree by 7th decade of life -Risk of bone loss increased by estrogen reduction, obesity, inactivity, smoking, and excessive consumption of caffeine and alcohol Risk of fracture from brittle bones Postmenopausal women should have daily calcium intake of at least 1,000 mg Calcium from carbonate and citrate is most common form of supplement (should be taken with meal at doses of not more than 500 mg at one time to ensure optimal absorption)

Promotion of skin health

Avoid irritating agents -Drying agents -Rough clothing -Highly starched linens Promote activity, nutrition, hydration -Activity -Bath oils -Lotions -Massages Avoid excessive bathing or drying agents -Excessive bathing may be hazardous to the skin -Daily partial sponge baths -Complete baths or showers every 2 or 3 days Early treatment of pruritus and skin lesions -Prevents irritation, infection Avoid exposure to UV rays -Sun-screen lotion ranging from SPF 15 or greater -UV rays cause solar elastosis or photoaging -Loss of elasticity and wrinkling of the skin due to premature aging of the skin -Fair-skinned individuals who easily burn when in sun are high risk -Apply sunscreen to entire face and body 15 minutes before going outside and reapplied at least every 2 hours -Skin damage can occur on overcast days because UV rays can penetrate clouds Self-examination of moles or suspicious lesions -ABCDEs A-Asymmetry -If mole is not round or symmetrical -If one half of the mole is not similar to other half -Could be sign of melanoma B-Border Irregularity -Cancerous moles have irregular borders that may be uneven, ragged, notched, or blurred C-Color -Typical color is consistently brown throughout -A mole that has changed color over time or is varied in a shade of brown, tan, and black may be cancerous -If melanoma has progressed, mole may become red, blue, or white D-Diameter -Cancerous moles can be more than 6 mm in diameter (about 1/4 in. or the size of pencil eraser) E-Evolving -Elevation in height from skin surface both horizontally or vertically -Change in feeling (such as itchiness, tenderness, pain) -Tendency to bleed if scratched

Helping family and friends after a death

Be available to provide support -Some people wish to have several minutes in private with deceased patients to view and touch them -Others want the nurse to accompany them as they visit the deceased -Others may not want to enter the room at all Variety of responses related to body viewing -Be careful not to make value judgments of the family's reactions based on their own attitudes and beliefs Encourage open expression of grief/feelings -Beneficial to express grief openly -Crying and shouting may help people cope with and work through their feelings about the death more than suppressing their feelings Guidance with funeral/burial arrangements -Require guidance by a professional -People should be encouraged to learn about funeral industry and plan in advance for funeral arrangements -Memorial societies can assist individuals in their planning Identify an advocate for help with planning -Family and friends are grieving, and they are vulnerable and susceptible to sales pitches equating their love for deceased to cost of the funeral. -Realistic questions concerning the financial impact of such funeral (whether it is nurse, member of clergy, neighbor; have someone advocate for the family and prevent them from being taken advantage of) Support through grieving/bereavement -After funeral and fewer visitors are calling to pay respects, full impact of death may first be realized -At time when most intense grief occurs, fewer resources may be available to provide support -Geri nurse can arrange for a visiting nurse, church member, social worker, or someone else to check on the family members several weeks after the death to make sure they are not experiencing any crisis -Widow-to-widow and similar groups can support individuals through grieving process -Provide telephone number of a person whom family can contact if assistance is required

Ethical Principles

Beneficence Do good for patients -Based on the belief that education and experience of nurses enable them to make sound decisions that serve patients' best interests Nurses are challenged to take actions that are good for patients while not ignoring patients' desires To override patients' decisions and invoke professional authority to take actions that nurse views as in patients' best interests is viewed as paternalism and interferes with freedom and rights of patient Nonmaleficence To prevent harm to patients Could be viewed as a subset of beneficence because the intent is ultimately to take action that is good for patients. EX: -Not directly performing an act that causes harm -Actions such as informing management that staffing is inadequate to provide safe care Justice To be fair, treat people equally, and give patients the service they need Belief that patients are entitled to services based on need, regardless of the ability to pay Scarce resources have challenged this concept of unrestricted access and use of health care services Fidelity Respect our words and duty to patients Depends on trust and integrity This principle is central to all nurse-patient interactions because the quality of the relationship depends on trust and integrity implies strict and continuing faithfulness to an obligation, trust, or duty Keeping one's promises Veracity Truthfulness Depends on trust and integrity This principle is central to all nurse-patient interactions because the quality of the relationship depends on trust and integrity Older patients may have higher degrees of vulnerability than younger adults, may be dependent on the truthfulness of caregivers Providers be honest in their interactions with patients Autonomy Respect patients' freedoms, preferences, and rights Ensuring and protecting older patients' right to provide informed consent Confidentiality To respect the privacy; protected by HIPAA

Telephone Orders

Changes in patients condition and requests for new or altered treatments may be communicated over phone -Physicians may prescribe orders Order can be heard or written incorrectly or the physician can deny that the order was given How to minimize risks -Faxed written order, sent online securely, entered directly into EMR -No third parties (do not have order communicated by a secretary or other staff member for nurse or the physician) -Assure all relevant information is communicated (such as vital signs, general status, and medications administered) -Do not offer diagnostic interpretations or medical diagnosis of the patient's problem -Write down order as given and read back in entirety -Place order on physician's order sheet and indicate telephone order, also the physician who gave it, time, date, and the nurses signature -Indicate it's a telephone order -Have signed within 24 hours by physician **Recorded telephone orders may be helpful for nurses to validate what they heard BUT... Lawsuit can occur UNLESS... Physician is informed conversation is being recorded OR special equipment with a 15-second tone sound is used.

Respiratory Alterations in older adults

Chronic respiratory disease -About 1 in 7 middle aged and older US adults have a lung disorder, such as asthma or COPD -1/3 of them report moderate to severe respiratory symptoms -Person may feel a loss of control over their lives D/T breathlessness on exertion and at rest They may become demanding and controlling in dealing with family and friends Respiratory disease is divided in 2 categories: obstructive pulmonary disease and restrictive pulmonary disease Obstructive Pulmonary Disease -Asthma -Chronic Bronchitis -Emphysema -Changes in expiratory airflow rates, obstruction of airway (airflow limitations) -The lumen of the airway can be decreased by mucus or edema of the airway, causing bronchoconstriction, which leads to wheezing -Difficult to exhale air in lungs Symptoms: -Cough -Chest discomfort -Wheezing -Coarse crackles -SOB Restrictive Pulmonary Disease -Pneumonia -Pulmonary fibrosis -Obesity -Mass (such as cancer) -Changes in chest wall, lung tissue, pleural space, body mass -Decreased ability to expand chest -Impaired inhalation -Decreased lung volume -Difficult to fully expand lungs with air Symptoms: -SOB (especially with exertion) -Cough -Wheezing -Difficulty inhaling air

Respiratory distress at end-of-life

Common problem in dying patients Physical discomfort of dyspnea Psychological distress from fear, anxiety, helplessness that results from thought of suffocating Causes: -Pleural effusion -Deteriorating blood gas levels Interventions: -Elevate head of bed -Pace activities -Relaxation exercises -Administer oxygen -Atropine or furosemide to reduce bronchial secretions -Narcotics (Morphine vasodilates blood vessels; it relieves and pulls blood away from hear to relieve breathlessness)

Effects of the environment (safety)

Components of environment can facilitate or discourage mental and social activity Clocks, calendars, newspapers -Can promote orientation -Knowledge of current events Accessible books and magazines -Challenge the mind and expand horizons Games and hobbies -Help stimulate Placement of chairs in clusters or in busy but not heavily trafficked areas is conducive to interaction and involvement with larger world

Legal terms to know

Consent Granting of permission to have an action taken or procedure performed Durable power of attorney Allows competent individuals to appoint someone to make decisions on their behalf in the event that they become incompetent Duty A relationship between individuals in which one is responsible or has been contracted to provide service for another HIPAA Health Insurance Portability and Accountability Act of 1996 Assures confidentiality of health information and consumers' access to their health records Injury Physical or mental harm to another or violation of a person's rights resulting from a negligent act Malpractice Deviation from standard of care Negligence Failure to conform to the standard of care Private law Governs relationships between individuals and/or organizations Governs relationships between you and the hospitals you work for Public law Governs relationships between private parties and the government Governs relationships between you and I. Between two people. Standard of care The norm for what a reasonable individual in a similar circumstance would do

Physiologic Changes in Men- Andropause

Decline in testosterone -Begins in 3rd or 4th decade of life, although not in all men (this is how it differs from menopause) -Slow process; testes do not lose ability to produce some testosterone -Reduced muscle mass, energy, strength, stamina r/t decrease in testosterone -ED can occur -Breast enlargement, osteopenia (bones get weaker), osteoporosis (body loses too much bone), shrinkage of testes, reduced libido -Correlates with reduced sexual function, higher risk for developing DM II & CV disease Slowed arousal Less pre-ejaculatory fluid, decreased ejaculatory force, less intense Less firm erection, shorter-lasting erection Longer time to achieve another erection Continued fertility Self image -Sagging skin -Wrinkles -Gray, thinning hair Chronic illness and certain meds impact ability to achieve or maintain erection -Antihypertensives -Antidepressants Low testosterone levels are not a normal occurrence in all aging men. Androgen replacement therapy: -Not recommended for men with history of prostate or breast cancer Side effects and risks: -fluid retention -sleep disorders -breast enlargement or tenderness -prostate growth

How respiratory health changes in older adults

Decreased in older adults Tidal volume -Volume of air inhaled or exhaled per breath Inspiratory reserve volume -Volume of air inhaled in addition to normal Expiratory reserve volume -Max volume of air that can exhaled in addition to normal Vital capacity -Volume of air exhaled after maximal inhalation Increased in older adults Residual volume by as much as 25-50% -Volume of air left in lungs after maximum exhalation Functional residual capacity -Volume of air left in lungs after normal exhalation Unchanged in older adults Total lung capacity -Total volume of air in lungs after maximum inhalation

Basic competencies for nurses caring for older adults

Differentiate what? Differentiate normal from abnormal findings Assess what? Assess the older adult's physical, emotional, mental, social, and spiritual status and function ASSESS FUNCTION! Engage how? Engage the older adult in all aspects of care to the maximum extent possible Actively involved in care Provide what? Provide information and education on a level and in a language appropriate for the individual Resources, safety, education! Educate on safety. Use appropriate level of language.

Complementary therapies for pain management

Discussion of possible therapies and interventions Acupressure Use of pressure over points along meridians to unblock energy flow and restore or promote balance of qi Acupuncture Placement of needles under skin at acupoints along meridians to unblock energy flow and restore or promote balance of qi Aromatherapy Branch of herbal medicine that uses scents from the essential oils of plants to create physiological and emotional effects Biofeedback Process of teaching people to bring specific bodily functions under voluntary control Chiropractic Use of manipulation or adjustment of the spine and joints to correct misalignments that can be causing dysfunction and pain Electrical stimulation Use of electrical currents administered to skin and muscles via electrodes placed on painful part of body Exercises Gentle stretching and range of motion exercises Guided imagery suggesting images that can create specific reactions in the body Heat and cold therapies Use of hot or cold pads, packs, dips, baths, massage, or environments (sauna) Herbal medicine use of plants for therapeutic benefit Homeopathic remedies Use of dilute forms of biological material (plant, animal, mineral) that produce symptoms similar to that caused by disease or condition Hypnosis Guiding person into trancelike state in which increased receptivity to suggestion is possible Massage Manipulation of soft tissue by using rubbing, kneading, rolling, pressure, slapping, and tapping movements Meditation using deep relaxation to calm body and mind and focus on present Naturopathy use of proper nutrition, pure water, fresh air, exercise, rest, and other natural means Osteopathy branch of physical medicine that uses physical therapy; joint manipulation and postural correction Prayer petition to God or other divine power through direct praying Progressive relaxation series of exercises that help body achieve a state of deep relaxation Supplements use of specific nutritional products Touch Therapeutic touch and healing touch are forms of energy healing in which caregiver places hands over various parts of patients body to manipulate patients energy field Need for nursing knowledge -Uses and contraindications of complementary therapies -Licensing requirements (help find qualified therapists) Patient education and counseling -Ensure patients make informed choices about their therapists

Sensory stimulation (safety)

Environment that is pleasing to the senses -Textured wall surfaces -Soft blankets and spreads -Differently shaped and textured objects to hold (round sheepskin covered throw pillow and a square tweed-covered one) -Murals, pictures, sculptures, and wall hangings -Plants and freshly cut flowers -Coffee brewing, food cooking, perfumes, oils -Birds to listen to and animals to pet -Soft music Different areas of living space can be created for different sensory experiences -Appetite of nursing home residents could be much improved if, within dining area, they could smell aroma of their coffee brewing or bread toasting (rather than just placing finished product on tray before them) Interventions for those who are bed-bound -Change wall hangings regularly -Provide sensory stimulation using different textures, shapes, colors, fragrances

Changes increasing ethical dilemmas for nurses

Expanded role of nurses -Beyond confines of simply following doctors' orders and providing basic comfort and care. Now... -Perform sophisticated assessments -Diagnose nursing problems -Monitor and give complicated treatments -Use alternative modalities of care -Increasingly make independent judgements about patients' clinical conditions Medical technology -Artifical organs -Genetic screening -New drugs -Computers -Lasers -Ultrasound Determining on whom, when, and how this technology should be used New fiscal constraints -Being cost-effective -Minimizing bad debts -Developing alternate sources of revenue Patients' needs are weighed against economic survival In this era of rationed care and scarce resources, questions are raised regarding the right of older adults to expect a high quality and quantity of health and social services while other groups lack basic assistance Conflicts of interest EXAMPLES: - Nurse, believing a resident's life could be extended with nasogastric feedings and antibiotic therapy, feeling that a resident's and family's rejection of this care is inappropriate -Patients physical therapy discontinued due to insurance restrictions and the nurse knowing that the patient has potential to make continued progress with therapy -Nurse knowing the employer is intentionally keeping staffing levels below what is needed but not objecting or advocating for proper staffing because nurse does not want to jeopardize his or her position Greater number of older adults Entitlement programs and services for older people had less impact when only a small portion of the population was old Growing numbers of people spending more years in old age and increasing ratio of dependent individuals to productive workers, society is beginning to feel burdened. The ability and responsibility of society to support these needs are in question Assisted suicide -ANA has been clear in its objection to assisted suicide Nurses may discuss options with terminally ill individuals who accept and desire assisted suicide Nurses also have the right to conscientiously object to being involved in aiding assisted suicide Laws have been enacted in some states to allow terminally ill persons to end their lives with lethal medications, and individuals have the right to refuse care under self-determination directives A few states that do not have laws supporting physician-assisted suicide have allowed it through individual court decisions

Pain at end-of-life

Fear is common -Concern regarding degree of pain that will be experienced and its management may be source of distress Can be managed effectively -Reduce distress for patients by supplying them with realistic information regarding pain -Patients with cancer are more likely to experience severe pain than other causes Patients perceive and express pain differently based on many factors -Patients will perceive and express pain differently based on medical diagnosis, emotional state, cognitive function, and other factors Indicators of pain: highly individualized -Complaints of pain or discomfort -nausea -irritability -restlessness -anxiety -No expression of pain -Sleep disturbances -Reduced activity -Diaphoresis -Pallor -Poor appetite -Grimacing -Withdrawal -Confusion Regularly assess pain -Can increase or decrease over time -Report their pain in a timely manner and openly discuss concerns about pain -Rate on scale of 0-10. Prevention is the goal -Palliative care is care that prevents and relieves pain in persons with incurable conditions -Palliative care can be provided to persons who are not dying -Helps patients avoid discomfort but reduces amount of analgesics they use Pain management interventions Establish schedule for pain medications Meperidine and Pentazocine are contraindicated for pain control because of high incidence of adverse effects at low dosages Mild pain: -Aspirin -Acetaminophen Moderate pain: -Codeine -Oxycodone Severe pain: -Morphine -Hydromorphone Alternatives to medications -Guided imagery -Hypnosis -Relaxation exercises -Massage -Acupressure -Acupuncture -Therapeutic touch -Diversion -Application of heat or cold Even if they can't substitute for medications, they could reduce amount of drugs used KEY CONCEPT: For the dying patient, the goal is to PREVENT pain from happening rather than trying to treat it once it occurs

Furniture (safety)

Furnishings SHOULD be: -Appealing -Functional (ability to clean) -Comfortable Examples of appropriate furniture: -Chairs with arm rests (provides support and assistance in rising from or lowering into seat) -Not so low or with sinking cushions (difficult to use) -Chairs appropriate height to allow feet to rest flat on floor with no pressure behind knees -Rockers (help relax and promote exercise) -Love seats instead of sofa (arm rests closer) -Recliners (leg elevation) -Sturdy Leather and vinyl coverings are more useful than cloth (easy to clean) -Should be fire resistant, with firm surface without buttons or seams in areas that come in contact with body -Rather than the back, seat, and arm rest being one connecting unit, open space where these sections meet allows for ventilation and easier cleaning Tables, bookcases, and other furniture should be sturdy and able to withstand weight from person leaning for support If table lamps used, bolt them to the table surface to prevent from being knocked over in attempt to locate in dark Foot stools, candlestick tables, plant stands, and other small pieces of furniture would be best placed in low-traveled areas (if present at all) Furniture and clutter should not obstruct path from bedroom to bathroom Drawers checked for ease of use -Sanding and waxing the corners and slides can facilitate movement In hanging mirrors, height and function of user must be considered Individuals with cognitive impairments need particularly simple environment -Use of furniture should be clear

Cancer risk factors

Habits, such as smoking, drinking, excessive exposure to UV, being obese, having unsafe sex can contribute (HPV, human papillomavirus, a viral infection) Diet, heredity/family history, health conditions (Ulcerative colitis can increase risk of certain cancers) Second hand smoke, chemicals in workplace (asbestosis), benzene Heredity -Certain types of cancers: breast, ovarian, uterine, or colorectal cancer Diet -High fat, chemicals in meat, fried or barbecued meat -Inconclusive research related to food additives, aspartame, and coffee Drinking water -Contamination Tobacco -Smoking as a significant cause of many types of cancer Alcohol -Increased risk of certain types of cancer Radiation/UV -Risk of skin cancer Occupational exposure to carcinogens Radon SINGLE MOST IMPORTANT RISK FACTOR FOR CANCER IS: AGE!!!!!!!! -More than half of the people diagnosed with cancer are over age 65 years

Congestive Heart Failure (cardiovascular)

Incidence increases with age Leading cause of hospitalization Causes: -CAD (responsible for most cases of CHF) -Rises in BP (HTN) -Reduced elasticity and lumen size of vessels -Decreased cardiac reserve = limits heart's ability to withstand effects of disease or injury Assessment and findings: -Dyspnea on exertion (most common finding) -Confusion -Insomnia -Wandering during the night -Agitation -Depression -Anorexia -Nausea -Weakness -Shortness of breath -Orthopnea -Wheezing -Weight gain -Bilateral ankle edema -On auscultation, moist crackles are heard New York Heart Association Classification 4 categories of CHF that can be used in classifying severity of the disease and guiding treatment Class 1 -Cardiac disease without physical limitation -No symptoms with ordinary physical activity Class 2 -Symptoms experienced with ordinary physical activity -Slight limitations may be evident of physical activity Class 3 -Symptoms experienced with less than ordinary activities -Physical activity significantly limited Class 4 -Symptoms experienced with any activity and during rest -Bed rest may be required Management of CHF -Consists of bed rest -ACE Inhibitors -Beta blockers -digitalis -Diuretics -Reduction in sodium intake -Patient may be allowed to sit in chair next to bed (to avoid development of thrombosis and pulmonary congestion) Presence of edema and poor nutrition of tissues associated with this disease -More fragile skin (greater risk of skin breakdown) -Regular skin care and frequent changes of positioning are essential

Self-medication errors

Incorrect dosage Noncompliance related to misunderstanding Discontinuing drugs without medical advice Use of medications from previous illnesses Functional limitations Impairment in ability to perform activities of daily living -Inability to travel to pharmacy to have prescription filled -Problems removing lids from med containers -Difficulty pouring the drugs or obtaining fluids to take with them -Impaired swallowing Cognitive limitations Impairments that prevent them from remembering to take medications -Make them forget that they did take the medication and retake them -Cause them to confused medications, dosage, or schedule Educational limitations Difficulty reading and understanding instructions and labels Sensory limitations Hearing deficits can cause instructions to be missed or misunderstood -Poor vision can prevent labels and instructions from being adequately seen Financial limitations Limited funds could cause not to fill prescriptions -Skip dosages -use old prescription -Use someone else's similar medication Choice -Conscious decision to not take medications due to dislike of effects -Poor motivation -Preference to use money for other things -Denial of condition

Tips for safe drug use: teaching tool

Keep a current list of al of the following that you use and show it to your health care provider -Prescription drugs -OTC drugs -Vitamins, minerals, and other nutritional supplements -Herbal and homeopathic remedies For each drug, herb, homeopathic remedy, or nutritional supplement that you use, know (and if possible write this down) the following: -Dosage -Administration schedule -Administration instructions -Purpose -Usual side effects -Adverse effects that you should bring attention to HCP -Precautions -Storage instructions -Where purchase/obtained Learn as much as you can about the drugs you are taking by reading literature that comes with the drug and consumer drug reference books Recognize that your drug dosage may be different from someone else's dosage who is taking the same drug Be aware that you can develop adverse effects to drugs that you have taken for years without problems. Review any symptoms you have with your HCP Try to reduce the drugs you are using. Discuss with your HCP improvements in your symptoms or other changes that could cause a drug to no longer be needed Periodically review your drug dosages with your HCP to see if any changes in your body's function could lead to reduced dosages Try to manage new symptoms naturally rather than with drugs Do not take new drugs without consulting your HCP

Advanced directions at end-of-life

Legal document that allows patients to express their desires regarding terminal care and life-sustaining measures Patient Self-Determination Act -All health care facilities and agencies that receive Medicare and Medicaid funding must provide info about this -It gives individuals the right to express their choice regarding medical and surgical care and to have those preferences honored at a later time if they are unable to communicate it. Nurses need to determine if patients have advance directives, review the patients wishes, and place the document in the medical record -Nurse should review advance directive with patient to assure it continues to reflect patient's preference -Place copy in medical record to inform all members of team Some states use MOLST (Medical orders for life-sustaining treatments) forms and POLST (Physician orders for life-sustaining treatments) forms -THESE ARE NOT ADVANCED DIRECTIVES -Developed through conversations with health care professionals involved in their care to describe specific medical treatments that they wish to have during a medical emergency -They are not legal documents that describe desired future care, nor do they contain information as to surrogates who can make medical decisions on their behalf KEY CONCEPT: An advance directive protects the patient's right to make decisions about terminal care and eases some of the burden of family members during this difficult time

Altered Pharmacokinetics: Metabolism and Detoxification

Most drugs are metabolized in the liver -This enhances drug excretion through kidneys Older people's liver function is reduced D/T lessened blood flow in liver and less enzyme activity With reduced liver function, rate at which drugs are metabolized slows = creates potential drug toxicity Conditions decreasing metabolism that can result in drugs reaching toxic levels: -Dehydration -Hyperthermia -Immobility -Liver disease Extended biological half-life -When kidney function is reduced, the biological half-life of a drug may be greatly increased -This allows it to reach levels that trigger adverse reactions Drug clearance -Extended biological half-life of many drugs warrants close evaluation of drug clearance -Estimated creatinine clearance must be calculated based on age, weight, and serum creatinine level Enzymes and metabolism -Reduced secretion of some enzymes = interferes with metabolism of drugs that require enzymatic activity -Includes cytochrome p-450 enzyme system that metabolizes bioactive substances such as HERBS in addition to meds -So drugs stay in bloodstream longer KEY CONCEPT: The extended biological half-life of drugs in older adults increases the risk of adverse reactions

During a home visit, the nurse notes that an older patient has increased joint pain and shortness of breath since moving in with her daughter 6 months ago. What could be contributing to this patient's complaints?

Most likely this is caused by family assistance limiting her mobility Immobility is a major threat to pulmonary and joint health. Well meaning families can sometimes limit activity rather than promote it, which can contribute to her complaints

Medications for pain

Need for appropriate analgesic use in the older adult High risk for adverse effects Close monitoring Begin with weakest type and lowest dosage and increase gradually Use narcotics with caution D/T high risk for falls, delirium, decreased respirations, and other side effects High risk for injury and other side effects -Recommended that meperidine, indomethacin, pentazocine, and muscle relaxants not be used for pain relief in older adults due to high risk of adverse effects Non-narcotics administered with narcotics -Administering a nonnarcotic analgesic with narcotic could decrease amount of narcotic that is needed Regular administration of analgesics to promote pain control -Administered regularly to maintain constant blood level Fear of addiction -Should not be a factor in appropriately using analgesics to assist patients in achieving relief

Spiritual care needs

Nurses need acknowledge of different religious views related to death and dying -Promotes fulfillment of patient's spiritual needs Assessment of religion and spirituality including individual practices -Assessment should explore religious affiliation -Individual religious practices Religion and spirituality are not the same -Religion is but one aspect of spirituality -Patients can be highly spiritual without religious affiliation -"What gives you the strength to face life's challenges?" -"Do you feel a connection with a higher being or spirit?" -"what gives your life meaning?" Inclusion of clergy and members of the individual's own faith-based group -Should be invited to be actively involved with patient and family, according to their wishes Role of the nurse -If nursing staff feel comfortable, they can offer to pray with patients -Read to them from religious texts

Supporting the dying individual

Nurses need to be more involved in the dying process -Used to be more prepared to deal with care of dead body than with dynamics of dying process -More detached, less spoke out, secret, isolated Humanistic approach to caring for dying patients and their families -Emphasis on meeting total needs of patient in holistic manner -Now recognition that family members and significant others play vital role Increased knowledge in field of thanatology -Scientific study of death and the practices associated with it -Including study of the needs of the terminally ill and their families -Can be certified Hospice care -Growing specialty -Way of caring for terminally ill individuals and their families Involves interdisciplinary efforts to address physical, emotional, and spiritual needs including: -pain relief -symptom control -home care and institutional care -social work and counseling services -medical equipment and supplies -volunteer assistance and support -bereavement follow-up and counseling -Medicare benefit Need for individualized nursing interventions Patient's reactions to dying are influenced by: -Patient's previous experience with death -Religious and spiritual and cultural beliefs -Philosophy of life -Age -Health status Need for careful assessment of experiences, attitudes, beliefs, and values of each individual -To be able to give the most therapeutic and individualized support

Considerations for Medication use and the older adult

Observation of responses to medications -Closely observe to determine if drug and its schedule of administration are appropriate Scheduling pain medications -Around the clock dosing or use of sustained-release drugs is useful in management of continuous pain -Medications administered on schedule to PREVENT pain rather than treat it after it develops Regular re-evaluation of the patient's response to pain medications -Medications may change effectiveness over time, necessitating change in prescription Assessment for side effects and adverse reactions -Side effects and adverse reactions can develop with drugs that have been used for long time without incident

Sexual behavior in older adults

Older adults can and do enjoy sex General pattern of sexual behavior is consistent throughout life -Includes homosexuality, masturbation, desire for a variety of sexual partners and other sexual patterns also continue into old age Sexual activity can be inhibited or negatively impacted by several factors -physiological changes -cultural forbidden issues -rigid morality -negative self-images -chronic illness -medications Menopause -Low libido -Brain fog -Vaginal dryness and atrophy -Don't sleep well Andropause (for men) -Lose testosterone -Can't maintain erection as well -Take medications; beta blockers contribute to ED Sexual role identification changed over time -Used to be that men are to be aggressive, independent, strong -Women are pretty, gentle, dependent on males Baby boomers have changed those views -Encouraged women to be independent, strong, and on equal terms with men in home and the workplace Results in diversity in sex role identity and expectations among older population

Summary of comfort and pain management

Older adults should receive regular pain assessment and appropriate pain management to improve comfort and quality of life Monitor routinely, reassess at frequent intervals Older adults experiencing acute pain usually show obvious physical signs of distress whereas those experiencing chronic pain, often show few obvious outward signs Pain management is critical because unrelieved pain may lead to: -Sleep disturbances and fatigue -Decreased mobility, chronic pain, and depression -Stress responses

Supporting family and friends through the stages of the dying process

Once patient dies, your job is to become resource for the family. Family and friends may also pass through the stages of the dying process before they accept the impending death of a loved one In denial stage -Family and friends may discourage patients from talking or thinking about death -Visit patients less frequently -State that patients will be better as soon as they return home, start eating, have their IV tube removed, etc. -May shop around for a doctor or hospital to find a special cure for the terminal illness In anger stage -Reactions may include criticizing staff for care they are giving -Reproaching family member for not paying attention to patient's problem earlier -Questioning why someone who has led such a good life should have this happen In bargain stage -Tell staff that if they could take the patient home they know they could improve his or her condition -Through prayers or open expression they may agree to take better care of the patient if given another chance -May consent to some particular action (going to church regularly, volunteering for good causes, giving up drinking) if patient could live to a particular time In depression stage -Become more dependent on staff -May begin crying and limiting contact with patient In acceptance stage -Wanting to spend a great deal of time with dying person -Tell staff of good experiences they have had with patient -Say how they will miss the person -May request the staff to do special things for patient (arrange for favorite foods, eliminate certain procedures, provide additional comfort measures) -Frequently remind staff to be sure to contact them "when the time comes" -Begin making specific arrangements for their own lives without the patinet (change of housing, plans for property, strengthening other relationships for support) Nurses support and interventions depend on what stage the family member or friend is at the time of encounter -Be aware of discrepancies in states (patient may accept death and discuss impact of their death, while family and friends may be at different stages and not able to deal with patients acceptance) -Provide individualized therapeutic interventions -While providing appropriate support to family and friends as they pass through the stages, nurse can offer opportunities for dying people to discuss their death openly with receptive party

Family experience with the dying process

Past -Higher mortality rates -Death in the home viewed as natural process -Fewer hospitals and other institutions **This change is due in part to decreases in mortality rate over the years*** Present Limited experience with death -most people have minimal direct involvement with dying individuals -Death has become more impersonal and unusual event Difficulty accepting one's own mortality -Understanding one's own mortality can be therapeutic to the nurse personally, as well as helpful in the care of dying individuals -Discussions about death, making a will and other plans related to one's own death is good clue to internalization of one's mortality -Nurses who understand their own mortality are more comfortable helping individuals through dying process Change in the site and circumstance of death -Previously viewed as natural processes, most births and deaths were managed by familiar faces in familiar surroundings -More deaths NOW occur in hospital setting or instituion

Patient Consent

Patients are entitled to know full implications of procedures Patients must have the ability to make independent choices and decisions Consent must be obtained prior to any medical/surgical procedure -Performing procedures without consent can be considered battery -Blanket consent forms that patients may sign that authorize staff to do anything required for treatment and care are not valid safeguards and may not be upheld in court. Consent must be informed -A written consent that describes the procedure, its purpose, alternatives to the procedure, expected consequences, and risks should be signed by patient, witnessed, and dated -Person performing the procedure (physician or researcher) be the one to explain the procedure and obtain the consent -Nurses CAN'T obtain consent for the physician because it is illegal and might not be able to answer medical questions patient might have -Nurses CAN play role in consent by ensuring that it is properly obtained, answering questions, reinforcing information, and making physician aware of any misunderstanding or change in desire of patient. -The nurse is responsible and accountable for the verification of and witnessing that the patient or the legal representative has signed the consent document in their presence and that the patient, or the legal representative, is of legal age and competent to provide consent. Nurses should not influence patients' decision Mental status must be considered -Patients who do not fully comprehend or have fluctuating levels of mental function are incapable of granting legally sound consent Consent should be obtained for anything that exceeds basic, routine care measures. -Any entry into body (either by incision or through natural body openings) -Any use of anesthesia -Cobalt or radiation therapy -Electroshock therapy -Experimental procedures -Any type of research participation -Any procedure, diagnostic or treatment, that carries more than a slight risk IF CONSENT IS DENIED: -Useful to have patient sign a release stating that consent is denied and patient understands risks associated with refusing consent -If patient refuses to sign the release, this should be witnessed and both should sign a statement that documents the patient's refusal for medical record

Patient competency

Persons who are mentally incompetent are unable to give legal consent Next of kin may not be legal guardian and may not be able to give consent -Appointment of a guardian to grant consent for individual is the responsibility of the court -When patient's competency is questionable, staff should encourage family members to seek legal guardianship of the patient or request assistance of state agency on aging in petitioning the court for appointment of a guardian -Unless they have been judged incompetent by a judge, people are entitled to make their own decisions Guardianship differs from power of attorney for healthcare -Guardianship is LEGAL and COURT APPOINTED -If not appointed by the court as a guardian, then you can't make any decisions for them -Guardian is monitored by court to ensure they are acting in best interests of incompetent individual Guardianship Court appointed of an individual or organization to have the authority to make decisions for an incompetent person. Guardians can be granted decision-making authority for specific types of issues: -Guardian of property (conservatorship): allows guardian to take care of financial matters but not make decisions concerning medical treatment -Guardian of person: decisions pertaining to consent or refusal for care and treatments -Plenary guardianship (committeeship): all types of decisions pertaining to person and property can be made by guardians under this form Power of attorney Legal mechanism by which competent individuals appoint parties to make decisions for them; this can take form of -Limited power of attorney: decisions are limited to certain matters (financial affairs for example) and power of attorney becomes invalid if individual becomes incompetent -Durable power of attorney: provides a mechanism for continuing or initiating power of attorney in the event the individual becomes incompetent THE DIFFERENCE!: -Power of attorney is a mechanism used by competent individuals to appoint someone to make decisions for them -Usually power of attorney becomes invalid if indivdiual granting it becomes incompetent, except in case of durable power of attorney (which is recommended for dementia & other disorders that are anticipated to decline-- so they can pick someone when they are still competent) -In guardianship, the court chooses who will act as guardian.

Altered Pharmacodynamics

Pharmacodynamics refers to the biologic and therapeutic effects of drugs at the site of action or on the target organ Limited information in the older adult population Differences known to date: -Increased myocardial sensitivity to anesthesia -Increased CNS receptor sensitivity to narcotics, alcohol, and bromides Greater therapeutic effects or likelihood of toxicity can result from age-related changes in pharmacodynamics -Changes in site of action determine individuals responsiveness to drug -Older adults are more sensitive to certain drugs, whereas sensitivity to other drugs may decrease with age

Altered Pharmacokinetics: Absorption

Pharmacokinetics is the absorption, distribution, metabolism, and excretion of drugs Older people have fewer problems in area of drug absorption than with distribution, metabolism, and excretion of drugs Effect of age-related changes -Slower absorption Factors that can alter drug absorption: Absorption and route of administration -Inhalation, topical, or IV most efficient Drugs given IM, SubQ, orally, or rectally are not absorbed as efficiently as drugs that are inhaled, applied topically, or instilled IV Concentration and solubility of drug -Drugs that are highly soluble (aqueous solutions) and in higher concentrations are absorbed with greater speed than less soluble and less concentrated drugs Diseases and symptoms can effect the absorption of drugs Can slow drug absorption (these are result of underlying disease states than normal age-related changes): -Decreased intracellular fluid -Increased gastric pH -Decreased gastric blood flow and motility -Reduced cardiac output and circulation -Slower metabolism -Pain and mucosal edema will slow absorption Conditions that increase absorption: -Diabetes mellitus -Hypokalemia Interventions to maximize absorption of drugs Encourage exercise -stimulates circulation -aids in absorption Properly used heat and massage -increase blood flow at absorption site Prevent dehydration Prevent hypothermia Prevent Hypotension Some considerations: -Preparations that neutralize gastric secretions should be avoided if a low gastric pH is required for drug absorption -Monitor for interactions -Using most effective administration route for drug

Effects of Aging on Medication Use

Polypharmacy definition: -Use of multiple meds and/or administration of more meds than are clinically indicated, representing unnecessary drug use and is common among elderly -Being prescribed five or more medications is considered polypharmacy -Occurs in more than 1/3 of older adults (more than 1/2 when OTC drugs are included) Number of drugs (risk of polypharmacy) -Older adults tend to take more medications -Most older people use at least one drug regularly -Median being seven prescribed medications Age-related changes that affect: Pharmacokinetics & Pharmacodynamics Results in increased risk for adverse reactions -Because of more health conditions in older population, drug use is increasing -Adverse effects of meds = confusion, dizziness, falls, F&E imbalances Effects of caffeine on medications!! -High caffeine intake = decrease effects of antiarrhythmics, cimetidine, iron, and methotrexate -Heighten the hypokalemic effects of diuretics -Increase the stimulant effects of amantadine, decongestants, fluoxetine, and theophylline Number of meds used increases with age -Taking more than one drug increases risk of drug-food interactions, in addition to herbal medicines

Respiratory Health Promotion

Prevention of infection Keep active -Maintain a healthy diet and exercise plan Influenza (annually) and pneumonia (at age 65 or older) vaccines -Receive appropriate immunizations -Influenza = 1 dose annually -Pneumococcal = 1 dose at age 65, possibly 2 depending on health condition Avoiding exposure -Avoid environmental and air pollutants -Avoid allergens Encourage deep-breathing exercises -Several times each day -While mobile or with reduced mobility -EX; Using an IS when their activity is reduced Smoking cessation -Avoid cigarette and secondhand smoke; even if they have smoked for many years, if they quit, they will benefit Promote mobility Decrease risks of immobility -Use masks, scarves, and filters to protect against community acquired illnesses -Stress management and relaxation, for breathing control -Immobility is a major threat to pulmonary and joint health. Sometimes families may limit activity rather than promote it. This would contribute to symptoms. Avoid self-treatment of respiratory problems -Early diagnosis and treatment of respiratory tract infections Review of medications and potential impact on respiratory function -Careful monitoring and adherence to medical regime for any chronic respiratory illnesses -OTC Cold meds can interact with prescription meds and cause serious side effects of complications Environmental considerations -Maintenance of a clean environment with clean air Consider outdoor air pollutants Improvement of indoor air quality Importance of a healthy oral cavity Hydration -Maintenance of adequate hydration (at least 64 ounces of water daily)

Professional Ethics

Principles that guide right from wrong conduct Gerontological nurses commonly face ethical questions regarding provision, scope, or cost of care for older adults Utilitarianism Good acts benefitting greatest number of people Greatest number of people will benefit and gain happiness Egoism Morally acceptable benefit for oneself Opposite of utilitarianism An act is morally acceptable if it is of the greatest benefit to oneself There is no reason to perform an act that benefits others unless one will personally benefit from it as well Relativism (Situation ethics) Right and wrong relative to the situation Some relativists believe there can be indivdiual variation in what is ethically correct Others feel that the individual's beliefs should conform to the overall beliefs of the society for the given time and situation Absolutism Specific truths to guide actions The truths can vary depending on a person's belief EX: A Christian's view may differ from an Atheist's view on certain moral behaviors A person who supports a political view of democracy may believe in truths different from those of a communist. EXAMPLE: Situation: Four poor old men who share a household. One day, one of these men finds a lottery ticket in the mailbox while checking the household's mail. The ticket holds winning number for a million dollars. Ethically, does he owe his housemates any of the winnings? Apply this to the issue of federal subsidies to older adults: Utilitarian -Could say that 14% of the population should not use 1/3 of the gross national product -Money instead should be equally allocated on a per capita basis Egoist -Would say that the individual old person should take whatever he feels he needs, regardless of the impact on others Relativist -Could say that older people can use this proportion of the budget unless more is needed for dependent children or defense, at which point it would no longer be right to do so Absolutists -Could hold various views depending on their belief systems, ranging from giving the older population whatever they need because of a moral responsibility to care for the sick and aged to withholding funds from the older population so that finances are available to build the military and meet specific political goals

Altered Pharmacokinetics: Distribution

Process by which drugs in bloodstream are sent throughout body Depending on chemical characteristics, drugs absorbed from intestinal tract pass into portal vein (Carries blood to liver) and partly metabolized by liver prior to entering blood stream where they are transported to various body parts -Absorbed from intestinal tract --> pass into portal vein --> metabolized by liver --> blood stream --> various parts of body Majority of drugs attach or bound to proteins in blood -Other drugs are not bound to blood protein and are free drugs in the blood -Blood proteins decline with age, reducing total number of usable binding sites -Older people tend to have increased amounts of free drug in the body = results in elevated drug levels in the blood Certain drugs such as Warfarin and NSAIDs are highly protein bound Can become dangerously high drug concentrations Difficult to predict drug distribution Considerations with the older adult: Change in circulation -Reduced cardiac output and diminished blood flow decreases amount of blood reaching body tissues -Affect in organs with a rich blood supply -May take more time for drugs to reach fatty tissue Membrane permeability -Aging process may also cause greater permeability of blood/brain barrier = allows certain drugs to enter CNS and cause unexpected neurological reactions Body temperature Tissue structure -Adipose tissue increases compared with lean body mass in older people (ESPECIALLY IN WOMEN) = Drugs stored in adipose tissue (lipid-soluble drugs) will have increased tissue concentrations, decreased plasma concentrations, and a longer duration in the body Monitoring: -When monitoring blood levels of medications, also evaluate the serum albumin level -Raising dosage of phenytoin because the blood level is low can lead to toxicity if the serum albumin is also low. KEY CONCEPT: When several drugs are taken at the same time, protein-bound drugs may not achieve desired results because of ineffective binding to reduced protein molecules

Age related changes in cardiovascular system

Prolonged cardiac cycle --> reduced exercise capacity -More time is required for the cycle of diastolic filling and systolic emptying to be completed Reduced heart rate --> ineffective response to stress and fever In general, HR of an old person does not increase in response to stress and fever as in a young person Instead, older client's heart is unable to meet the demands when there is a sudden physical exertion or emotional stress How does the heart compensate for the decreased cardiac output and contractility? -increasing systemic vascular resistance. Veins lose elasticity --> Reduced activity leads to lessened pumping action of calf muscles --> Veins dilate and blood pools in dependent areas --> causes edema in legs and feet --> blood flow to all organs decrease Arterial wall thickening, stiffening, decreased compliance, so reduced elasticity Left ventricular and atrial hypertrophy Heart valve becomes thicker and rigid Heart muscle is less efficient -Decreased contractile strength -Decreased cardiac output when demands on heart are increased Slightly slower heart rate -May develop fibrous tissue and fat deposits -Natural pacemaker (SA Node) loses some its cells Slight increase in left ventricle, but heart size unchanged in absence of pathology -Heart wall thickens, so amount of blood that the chamber can hold may decrease -Heart may fill more slowly Heart may fill more slowly Abnormal rhythms, such as atrial fib, are more common in older adults Valves inside heart thicken and become stiffer and may cause murmur -Heart muscle cells degenerate slightly -Valves inside heart thicken and become stiffer to cause murmur Takes longer for heart to return to baseline level Conditions that can alter tissue perfusion are often found in older adult -Cardiovascular disease (hypertension, CHF, varicosities) -Diseases (diabetes mellitus, cancer, renal failure) -Blood dyscarsias (anemia, thrombus, and transfusion reactions) -Hypotension (arising from anaphylactic shock, hypovolemia, hypoglycemia, hyperglycemia, orthostatic hypotension) -Medication side effects (antihypertensives, vasodilators, diuretics, antipsychotics) -Other conditions (edema, inflammation, prolonged immobility, hypothermia, malnutrition) Indications of ineffective tissue perfusion -Hypotension -Tachycardia, decreased pulse quality -Claudication -Edema -Loss of hair on extremities -Tissue necrosis, stasis ulcers -Dyspnea, increased respirations -Pallor, coolness of skin -Cyanosis -Decreased urinary output -Delirium (altered cognition and LOC) -Restlessness -Memory disturbance

Cardiovascular Health promotion

Proper nutrition AHA recommends limiting intake of: -Saturated fat -Trans fat -Cholesterol Total cholesterol = less than 200 LDLs = less than 100 HDLs = more than 60 Dietary guidelines for reducing risk of cardiovascular disease -Reduce intake of fried foods, animal fats, and partially hydrogenated fats (beware of fast foods) -Increase intake of complex carbohydrates and fiber. Use unrefined whole grain products such as whole wheat, oats and oatmeal, rye, barley, corn, popcorn, brown rice, wild rice, buckwheat, bulgur (cracked wheat), millet, quinoa, and sorghum -Maintain caloric intake between ideal ranges. -Use monounsaturated oils (canola oil, cold-pressed olive oil) and omega-6 oils (black currant oil, evening primrose oil) -Eat fish rich in omega-3 fatty acids (salmon, trout, and herring) at least twice weekly -Reduce intake of red meat, sugar, and highly processed foods -Limit alcohol beverages Physical activity is cornerstone of good health Lifestyle modifications -Smoking cessation -Weight loss -Stress management -Increase exercise Need for distribution of exercise throughout the week -Aerobic, strengthening, balance exercises, yoga, and t'ai chi Proactive interventions -Low-dose aspirin daily -Daily multivitamin supplement -Light/moderate alcoholic beverages

Provisions of The Code of Ethics

Provision 1 The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person -Human dignity -Relationships with patients -Nature of health -Right to self-determination -Relationships with colleagues/others Provision 2 The nurse's primary commitment is to the patient, whether an individual, family, group, community, or population -Primacy of patient's interests -Conflict of interest for nurses -Collaboration -Professional boundaries Provision 3 The nurse promotes, advocates for, and protects the rights, health, and safety of the patient -Protection of rights of privacy and confidentiality -Protection of human participants in research -Performance standards and review mechanisms -Professional responsibility in promoting culture of safety -Protection of patient health and safety by acting on questionable practice -Patient protection and impaired practice Provision 4 The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to promote health and to provide optimal care -Authority, accountability, responsibility -Accountability for nursing judgements, decisions, and actions -Responsibility for nursing judgements, decisions, and actions -Assignment and delegation of nursing activities or tasks Provision 5 The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth -duties to self and others -promotion of personal health, safety, well-being -continuation of personal growth Provision 6 The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care -Responsibility for healthcare environment Provision 7 The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy Provision 8 The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities Provision 9 The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain integrity of pression, and integrate principles of social justice into nursing and health policy

Pain assessment

Qualitative and quantitative assessment Open-ended questions for assessment are more effective than yes or no questions Physical examination Need for ongoing assessment Assessment guide Challenges to assessment Cognitive impairment -Not have ability to interpret or report symptoms -Greater burden falls on nurse to adequately identify and assess pain -Change in function, poor appetite, agitation, sleep disruptions, or refusal to participate in care or activities could be indications of pain -Asking family members norms about changes they may note can assist When such signs are identified, physical assessment should be performed to detect signs of abnormalities (abnormal lung sounds, abdominal sensitivity, reduced ROM, bruised limb, etc.) What tool will you use? Signs that could indicate pain in persons with cognitive impairments -Grimacing -Crying, moaning -Increased vital signs -Perspiration -Increased pacing, wandering -Aggressive behaviors -Hitting, banging on objects -Splinting or guarding body part -Agitation -Poorer function -Change in sleep pattern -Change in appetite or intake -Decreased socialization Consideration of cultural factors

Institutional care (safety)

Reaction of older adults to institutionalization -Depression over loss of health, personal possessions, and independence -Regression because of the inability to manage the stress at hand -Humiliation by having to request basic necessities and minor desires, such as toileting, a cup of tea, or cigarette -Anger at the loss of control and freedom Enhancement of the institutional environment -An attractive decor -Inclusion of individual's personal possessions -Respect for privacy and personal territory -Recognition of the individuality of the resident -Allowance of maximum control over activities and decision making -Environmental modifications to compensate for deficits Need for respect, individuality, and sensitivity -Superior interior decoration and lovely color schemes mean little when respect, individuality, and sensitivity are absent

General nursing considerations for respiratory conditions

Recognize symptoms and seek care -Older adults encouraged to seek prompt medical attention with signs of a respiratory infection Prevent complications Risk for undetected pneumonia -No signs of chest pain + they often have normal or lower body temperatures (body temp tends to normally run lower in older adults) Should be closely monitored to minimize disability and prevent mortality Promote safe oxygen administration -Use with caution to prevent effects of carbon dioxide retention and narcosis (condition that develops when excessive CO2 is present in the bloodstream, leading to a depressed level of consciousness.) Promote productive cough and postural drainage -Postural drainage = uses gravity to help move mucus from the lungs up to the throat. -Report changes in sputum (changes in consistency, color, volume, odor -Nonproductive coughing may be a useless expenditure of energy Measures taken to help promote productive cough: -Hard candy to increase secretions -Breathing exercises -Humidification -Expectorants -Maintaining appropriate fluid intake Promote self care (meds, equipment, teaching) -Encourage to quit smoking (even if smoked for a long time, can still be beneficial) -Taking medications correctly; can they manipulate inhaler? -May need lots of education Provide encouragement -Respiratory problems are frightening and can produce anxiety -Provide support and reassurance -Make sure they understand the disease & its management -Some patients may find it necessary to spend most of their time indoors to avoid extremes of hot and cold weather -Some may have to learn to transport oxygen with them as they travel outside of their homes

Colors (safety)

Red, yellow, white Can be stimulating and increase pulse, blood pressure, and appetite Blue, brown, and earth tones Can be relaxing Orange Can stimulate appetite Violet Can decrease appetite Green Can convey a sense of well-being -Master healer color Black and gray Can be depressing Wavy patterns & diagonal lines Disorienting; cause dizziness Contrasting colors Defines doors, stairs & level changes EXAMPLE: Bedrooms may be blue and green Eating and activity areas may be orange and red Lounge areas gray and biege

Nursing problems related to death & dying

Reduced activity level Causes: -Depression -Fatigue -Pain -Treatments -Immobility -Hospitalization -Weakness -Bed rest Anxiety, Depression Causes: -Separation from loved one -Loss of body function or part -Feelings of helplessness -Realization of impending death -Concern about treatment prior to and at death -Poor family coping -Dependency Constipation Causes: -narcotics -immobility -diet -stress Diarrhea Causes: stress, antibiotics, tube feedings, cancer, fecal impaction Risk for cardiac complications Causes: congestive heart failure, cardiogenic shock, anemia, fluid and electrolyte imbalances, drugs, stress Pain Causes: cancer, diagnostic tests, poor positioning, overactivity Difficulty communicating Causes: pain, drugs, fatigue Risk of infection Causes: cancer, renal failure, treatments, immobility, lowered resistance, drugs (e.g. antibitoics, steroids), malnutrition Fear Causes: -treatments -pain -family welfare -death Risk of dehydration Causes: -Shock -fever -infection -anorexia -inability to drink independently -depression Risk of pneumonia Causes: -thick secretions -drugs -immobility -decreased lung elasticity and activity Potential for injury Causes: -Altered ability to protect self -pain -drugs -fatigue -weakness Need for education Causes: -diagnostic tests -treatments -drugs -pain management Poor oral health Causes: -cancer -infection -drugs -malnutrition -dehydration -mouth breathing -poor hygiene Risk of skin breakdown Causes: -immobility -infections -edema -dehydration -emaciation Disturbed thinking Causes: -depression -anxiety -fear -isolation -effects of drugs or disease Family stress Causes: -concern over death of family member -changes in roles -cost of care Sleep disturbances Causes: -immobility -pain -anxiety -depression -drugs -new environment Limited socialization Causes: -loss of body function or part -depression -anxiety -hospitalization -reaction of others to current condition Unmet spiritual needs Causes: -Feelings toward dying process -questioning presence of God or higher power -Barriers to interactions with others -Inability to engage in religious activities Unmet sexual needs Causes: -separation from partner -pain -fatigue -depression -drugs -treatments -hospitalization

Hydration needs of older adults

Reduction in total body fluids that contribute to risk for dehydration -Intracellular fluid is lost --> resulting in decreased total body fluids -Water constitutes 50% or less of body weight in older adults -Reduces margin of safety any fluid loss Fluid recommendation for men vs women -Men = 16 glasses per day -Women = 11 glasses per day Factors that may cause older adults to consume less fluid Situations with hot climate or being on diuretic could increase fluid needs -Age-related reductions in thirst sensations -Fear of incontinence (physical condition and lack of toileting opportunities) -Lack of accessible fluids -Inability to obtain or drink fluids independently -Lack of motivation -Altered mood or cognition -Nausea, vomiting, and gastrointestinal distress Risks of fluid restrictions -Infection -Constipation -Decreased bladder distensibility -Lead to serious fluid and electrolyte imbalances Dehydration -Can be life-threatening to older people Demonstrated by: -dry, inelastic skin -Dry, brown tongue -Sunken cheeks -Concentrated urine -Blood urea value elevated above 60 mg/dL -Confusion Effects of over-hydration Caused by decreased cardiovascular and renal function -Consideration if intravenous fluids are needed therapeutically

Ethics in nursing

Require code of ethics on which practice can be based and evaluated. Internal ethical standards Ethical standards created inside of the nursing profession ANA Code of Ethics -Outline broad values of the profession The American Holistic Nurses Association has developed the Code of Ethics for Holistic Nursing -Provides guidance for nurses' actions and responsibilities for self, others, and the environment External ethical standards Ethical standards created OUTSIDE of the nursing profession; Federal, state, and local standards, in the form of regulations, guide the nursing practice -Federal, state, and local standards: regulations Joint Commission and American Healthcare Association: -Develop standards for specific practitioners and care settings Agency specific: -Individual agencies have philosophy, goals, and objectives that support a specific level of nursing practice Individual nurses -Values for ethical thinking -Important for nurse to understand his or her own values as conflict, and distress can result when nurse's values differ from those of the employer or population served

Effects of aging on respiratory health

Respiratory problems develop more easily in older adults & are more difficult to manage Structural changes cause decrease in respiratory activity -Change in shape of ribcage + more rigid -Increased AP diameter Posture --> Kyphosis -Bones are thinner, muscles of chest and spine weaken --> change in shape of ribcage --> kyphosis --> reduced functional space that is needed for lungs to properly expand and contract Breathing becomes more difficult, so theres an increase use of accessory muscles --> causes lower oxygen level in body --> with less CO2 removed from body --> person may exhibit of tiredness and SOB Decreased collagen and elastin result in: -Loss of elastic recoil in the lung -So less lung expansion -Smaller lungs -More rigid -Less recoil Older adults has less lung expansion, lungs are less elastic and more rigid Increased residual volume due to: -Decreased basilar lung expansion -Exhale less effective Decreased gas exchange due to: -Decrease in # of alveoli & lung capillaries Increased residual capacity and reduced vital capacity Less ciliary action--> Results in an increasing inability to clear mucus secretions --> Reduced cough and mucus clearance leads to greater respiratory infection risk --> high risk for aspiration As residual volume increases --> vital capacity is reduced --> maximum breathing capacity decreases --> placing older adults at high risk for developing respiratory infections

Risks associated with restraints & alternatives to restraints

Risks associated with restraints Restraints can cause serious injuries and worsen cognitive function -Consist of anything that restricts freedom of movement Types of restraints -Physical restraints: seat belts, vests, wrist ties, "geri-chairs," bilateral full-length side rails -Chemical restraints: drugs given solely for purpose of discipline or staff convenience Reduction in the use of physical restraints -Restraints can lead to serious complications (aspiration, circulatory obstruction, cardiac stress, skin tears and ulcers, anorexia, dehydration, constipation, incontinence, fractures, and dislocations) Need for thorough nursing assessment -Identifying factors that contribute to agitation and other negative behaviors -Addressing specific factor contributing to behavior could calm the patient and eliminate need for restraints Alternatives to restraints -Placing patient in room near nursing station (close observation and frequent contact) -One-to-one supervision and companionship (family members and volunteers can provide this) -Use of electronic devices that alert staff when patient attempts to get out of bed or leaves designated area -Repositioning, soothing, communication, touch, and other comfort measures -Frequent reality orientation and reassurance -Diversional activities

Sexually transmitted illness in older adults

Safe sex issues are ignored Risk for STDs Increase in AIDS for adults over age 50 -Accounts for 1 in 6 HIV/AIDS diagnoses in the US -Most older men who have HIV contracted it through sex with another male -Most older women who are infected became so through heterosexual contact Multiple partners(more than 1 in 12 months) without protection -May not consider condom because pregnancy is no longer a risk Misconception about STIs -May believe that these diseases only affect younger people Embarrassment, especially with HIV -May be too embarrassed to seek medical care -Also often attribute symptoms to normal aging Providers may not consider STD until advanced -Provider may not associate symptoms with HIV simply because person is old Important for nurses to reinforce safe sex practices to older persons and to ask about safe sex practices and risk factors for HIV during assessment.

Bathroom Hazards

Safety measures Lighting -A small light should be on in bathroom at all times (Because urinary frequency and nocturia are common, older adults use bathroom more often) -Constant lighting is helpful if switch is located outside the bathroom Floor surface -Towels, hair dryers, and other items should not be left on the bathroom floor -THROW RUGS NOT USED! -Leaks should be corrected to avoid creating sliperry floors Faucets -Lever-shaped faucet handles are easier to use than round ones or those that must have pressure exerted on them -Control hot water temperature centrally -Color coding the faucet handles makes differentiation of hot and cold easier Tubs and shower stalls -Nonslip surfaces are essential for tubs and shower floors -Grab bars on the wall and safety rails attached to the side of the tub offer support during transfers -A shower or bath seat offers a place to sit when showering -For tub bathers, a resting point when lifting to transfer out of the tub -Have seat alongside the tub to enable the bather to rest when drying (drop in BP following bathing) Toilets -Grab bars or support frames aid in the difficult task of sitting down and rising from toilet seat -Because low height of toilet seats make them difficult for many older people to use, a raised seat attachment could prove useful Electrical appliance -The use of electric heaters, hair dryers, and radios in the bathroom produces safety risk Seat by bathtub to rest while drying off

Older adults & Attitudes towards sex

Sex as a controversial subject -Sexual expression outisde of wedlock (society viewed sexual expression outside of wedlock as disgraceful and indecent) -Discussion about sexuality was minimal (discouraged and avoided in most circles. Interest in sex was considered sinful and improper.) -Education has helped erase mysteries of sex for both adults and children (sex courses, workshops, and counselors throughout country are helping people gain greater insight about and enjoyment of sex) Stigma attached to premarital sex been greatly reduced but also increasing numbers of unmarried couples are living together with society's acceptance. Sex now viewed as a natural, good, and beautiful shared experience Ignorance and prejudice related to sex continues -However, "natural, good and beautiful" are seldom used to describe sexual experiences of older adults -When topic of sex and older adults is confronted, ignorance and prejudice reappear -Signs of interest in sex or open discussions of sex by old people are often mocked, discouraged, or viewed suspiciously. Consequences of myths -Respect for older adults as vital, sexual beings is minimized by the lack of privacy afforded to them, by lack of credence given to their sexuality, and by lack of acceptance, respect, and dignity granted to continue sexual expression -They reinforce any fears and aversion the young have to growing old -Impose conformity on older adults, requiring that they either forfeit warm sexual experiences or suffer feelings of guilt. Older adults may not receive respect as sexual beings Violations of respect to sexual identity: -Belittle interest in clothing, cosmetics, and hairstyles -Dressing men and women in similiar asexual clothing -Denying woman's request for female aide to bathe her -Forgetting to button, zip, or fasten clothing -Unnecessarily exposing older indivdiuals during examination or care activities -Discussing incontinent episodes when peers are present -Ignoring mans desire to be cleaned and shaved before female friends visit -Ignoring attempts by older adults to look attractive -Not considering that spouse or partner can be of same sx -Joking about two senior citizens' interest in and flirtation with each other

Restraints

What is a restraint? Anything restricting movement (protective vests, trays on wheelchairs, safety belts, geriatric chairs, side rails, and medications) -Used for safety -Make a determination and weigh risks vs benefits; if they are demented and going to hurt themselves, pull out PICC line, rip foley out three times, then consider restraints. Omnibus Budget Reconciliation Act (OBRA) -Heightened awareness of the serious impact of restraints by imposing strict standards on their use in long-term care facilities -Imposes strict standards on use of restraints (both chemical and physical) -Alternatives to restraints should be used whenever possible -Provider order required with specific conditions -Agency must have a policy -Litigation for false imprisonment and negligence -Never used for convenience of staff Challenges? Delirium or dementia? Possible medication use -Haloperidol, Benzodiazepines, Lorazepam that are useful in reducing agitation and need for physical restraints BUT these can result in aspiration due to depression of gag reflex, pneumonia due to reduced respiratory activity -These are forms of chemical restraints and should only be used after other measures have been proven ineffective Alternatives should always be tried first: -alarmed doors -wristband alarms -bed alarm pads -beds and chairs close to floor level -increased staff supervision and contact -Specific patient behavior that creates risks to patient and others should be documented (include assessment of risk posed by patient not being restrained and effectiveness of alternatives) When deemed absolutely necessary = PHYSICIAN ORDER required! -stating specific conditions for which restraints are to be used -type of restraints -duration of use -Agency policies should exist -Detailed documentation include times for initiation and release of restraints, their effectiveness, and patient's response -Patient requires close observation while restrained Family refusal? Sometimes staff may assess the restraint use is required, but patient or family refuses to have restraint used. If counseling does not help patient and family understand the risks: -If family rejects or refuses, restraints may need signature on release of liability -Give them option to have a sitter

Negligence

What is negligence? Omission or commission of an act that departs from acceptable and reasonable standards. FAILURE TO CONFORM TO THE STANDARD OF CARE. Malfeasance Committing an unlawful or improper act -EX: A nurse performing a surgical procedure Misfeasance Performing an act improperly -EX: Including the patient in a research project without obtaining consent Nonfeasance Failure to take proper action -EX: Not notifying the physician of a serious change in the patient's status Malpractice Failure to abide by the standards of one's profession -EX: Not checking that a nasogastric tube is in the stomach before administering a tube feeding Criminal negligence Disregard to protecting the safety of another person -EX: Allowing a confused patient, known to have a history of starting fires, to have matches in an unsupervised situation Examples of situations that may result in negligence -Failing to take action (not reporting a change in the patient's condition or not notifying the administration of physician's incompetent acts) -Contributing to patient injury (not providing appropriate supervision of confused patients or failing to lock the wheelchair during a transfer) -Failing to report a hazardous situation (not letting anyone know that the fire alarm system is inoperable or not informing anyone that a physician is performing procedures under the influence of alcohol) -Handling patient possessions inappropriately -Failing to follow policies and procedures What's the difference in negligence and malpractice? Malpractice is when the person or the entity causes an injury to a patient THROUGH a negligent act. Negligence then could be an error in treatment or health management The most distinctive difference between the two is intent. -medical negligence is a mistake that resulted in causing a patient unintended harm. -Medical malpractice is when a medical professional knowingly didn't follow through with the proper standard of care. the injury was caused by an avoidable but unintentional mistake (medical negligence) OR an intentionally negligent action (medical malpractice).

Malpractice -- Important points. What four conditions must be present to warrant malpractice?

When performance deviates from the standard of care, we are liable for malpractice. In other words -- failure to abide by the standards of the nursing profession. This is negligence! FOUR CONDITIONS MUST BE PRESENT TO WARRANT MALPRACTICE: 1. Duty -The defendant owed a legal duty to the plaintiff under the circumstances Ex: a nurse owes a patient a legal duty to provide him or her with competent medical care 2. Breach -The defendant breached that legal duty by acting or failing to act in a certain way By doing (or not doing something) that a "reasonably prudent person" would do under similar circumstances. --legal standard that represents how the average person would responsibly act in a certain situation. 3. Injury -The plaintiff was harmed or injured as a result of the defendant's actions. 4. Proximate causation It was the defendant's actions (or inaction) that actually caused the plaintiff's injury. (Duty, negligence, and injury must be present for malpractice to exist) Examples of Malpractice -Med errors: identifying a problem like respiratory distress after giving a medication but not informing the provider in a timely fashion -Leaving an irrigating solution at the bedside and the patient drinks it -Forgetting to turn an immobile patient during the entire shift, resulting in the patient developing a pressure injury -Having a patient fall because one staff member attempted to lift the patient manually when the use of a lift device was the standard -Resuscitation when the patient is a DNR *Negligent acts do NOT always warrant that damages be covered* Must be aware of risks of practice and be proactive.

Menopause and Hormone therapy

Women's health initiative -Huge study on effects of hormones -Estrogen + Progestin increases stroke risk by 41% but decreases risk for hip fractures by 34% Must consider relative risk vs absolute risk Relative risk -Estimates percent increase or decrease in health event occurring in one group compared to another group Absolute risk -Estimates the number of health events among individuals in a group, and gives a better sense of personal or indivdiual risk Ok to control moderate to severe menopause symptoms -For most women, experts agree it's okay to control moderate to severe menopause symptoms within 10 years of menopause and up to age 59 -Women who started HRT within 10 years of menopause appeared to have lower risk of heart attack and breast cancer -Women who began taking hormones 10 or more years past menopause had significantly higher risk of heart problems Use lowest dose Risks include: -Stroke -Blood clots -Uterine cancer -Breast cancer -Coronary artery disease Current guidelines from NAMS conclude that HRT: -Should be individualized based on woman's age, time since menopause, personal health risks, and potential risks and benefits -Is most effective for treating vasomotor symptoms and genitourinary syndrome of menopause -Is effective in preventing bone loss and fracture -Has favorable risk-benefit ratio for women under age 60 years who are within 10 years of menopause and have no conditions that would contraindicate therapy -Has less favorable risk-benefit ratio for when aged 60 years and older who initiate therapy more than 10 or 20 years from menopause onset

Unique challenges for older persons with cancer

Advanced stage when initially diagnosed Breast cancer = 62 years of age Lung cancer = 70 years of age Prostate = 66 years of age Colorectal = 68 years of age ... So around 60-70s Multiple health conditions Increased risk of complications, disability, and death Treatment challenges -Older patient's already compromised organs will tolerate chemotherapy -Other cancer therapies could impact treatment decisions KEY CONCEPT: The increased incidence of cancer with age could result from age-related changes that reduce the ability to resist the disease or prolonged exposure to carcinogens

Coronary Artery Disease (Cardiovascular)

Angina Chest pain or discomfort due to lack of oxygen rich blood to heart muscle Atypical pattern in older adults -It makes detection difficult Signs and symptoms -First indication may be vague discomfort under sternum, frequently after exertion or a large meal -Precordial pain radiating down the left arm -Coughing -Syncope -Sweating with exertion -Episodes of confusion Recurrence of anginal symptoms over many years can result in formation of small areas of myocardial necrosis and fibrosis --> diffuse myocardial fibrosis occurs --> myocardial weakness --> risk for CHF Treatment -Nitroglycerin -More likely to experience orthostatic hypotension with nitrates resulting from loss of vasomotor and baroreceptor activity -This drug CAUSE DROP IN BLOOD PRESSURE! SO LOWER DOSAGES INDICATED -Cautions patient to sit or lie down after taking tablet to prevent fainting episodes and falls -Patients should not swallow saliva for several minutes after sublingual administration Nursing interventions to prevent angina -Avoid factors that aggravate problem (cold wind, emotional stress, strenuous activity, anemia, tachycardia, arrhythmias, and hyperthyroidism) -Acupuncture has shown to reduce frequency and severity For some patients, coronary angioplasty and stenting may be performed -Reduce severity of angina and coronary events Myocardial Infarction Incidence increases with age, men with history of hypertension, arteriosclerosis Diagnosis Atypical symptoms -Absence of pain or different in character or location -May appear as upper abdomen pain + SOB, fatigue, nausea Treatment -Reduce amount of time in which patient is limited to bed rest and to replace complete bed rest with allowing patient to sit in armchair next to bed -Arms should be supported to avoid strain on heart Early ambulation following MI is encouraged -Getting out of bed early can be beneficial for the heart Thrombolytic therapy commonly used; monitor for bleeding Fitness programs beneficial for coronary artery disease in improving cardiac functional capacity, reduce ischemic episodes, decrease the risk of complications, and promote a sense of well-being and control over the condition

Summary of SKIN HEALTH in older adults!

As a result of normal, age-related changes in the skin, older adults are more susceptible to skin tears and bruising caused by thinning of the skin Greater risk for hypothermia, shearing, pressure damage, and blunt trauma as result of decreased subcutaneous (fat) tissue Experience altered medication absorption as a result of an age-related decrease in fatty tissue and dermis blood supply Increased risk of heatstroke as a result of compromised cooling mechanism from decreased sweating Pruritus warrants full skin assessment because it can be indicative of many diseases, drug reactions, and possibly cancer -Nurse should determine the location, intensity, alleviating and aggravating events, onset, and what the client is doing to control it Notify the HCP if the following suspected lesions are found on assessment of actinic keratosis, BCC, SCC, or melanoma Venous hypertension leads to formation of capillary fibrin cuff, which causes chronic edema, decreased circulation, and recurring medial lower leg ulcers PREVENTION is first-line strategy for pressure injury care Assess nutritional status of patients with pressure injuries with determination of monthly weight and lab variables To minimize friction, use sheets to lift and pull patient up in bed and apply a film dressing or lotion to vulnerable areas such as elbows, coccyx, and heels To minimize shearing forces, do NOT elevate HOB greater than 30-34 degrees

End-of-life care terms to know

Assisted suicide Suicide committed with the help of another individual -Not legal in Texas Do not resuscitate (DNR) Medical order advising providers not to initiate cardiopulmonary resuscitation in the event of cardiac or respiratory arrest End of life Period when recovery from illness is not expected, death is anticipated, and focus is on comfort Hospice care Program that delivers palliative care to dying individual and support to dying person and that person's family and caregivers -It is a medicare benefit; palliative care is covered Palliative care Care that relieves suffering and provides comfort when cure is not possible Rational suicide Decision by competent terminally ill person to end his or her life -ILLEGAL!

Nursing Assessment of skin

Attention to skin status is essential to prevent complications -Nurses have best opportunity with most direct contact to assess the skin -Largest organ in the body!! Skin Surface Bathing and massages are good opportunities to inspect skin -Note moles, skin, tears, bruises, discoloration, and any other unusual finding -Areas of pressure may be difficult to detect in dark-skinned persons Lesions -Color, configuration, size, drainage, and type Macule -Small non-palpable spot or discoloration Papule -Discoloration less than 1/2 cm in diameter with palpable elevation Plaque A group of papules Nodule A lesion 1/2 to 1 cm in diameter with palpable elevation; skin may or may not be discolored Tumor A lesion greater than 1 cm with palpable elevation; skin may or may not be discolored Wheal A red or white palpable elevation that may occur in variable sizes Vesicle A lesion less than 1/2 cm in diameter that contains fluid and has palpable elevation Bulla A lesion GREATER THAN 1/2 cm in diameter that contains fluid and has a palpable elevation Pustule A lesion containing purulent fluid; of variable size and palpable elevation Fissure A groove in the skin Ulcer An open depression in the skin that may occur in variable sizes Mongolian spots -Many people of african, asian, or native american backgrounds have mongolian spots -Irregular, dark areas (resembling bruises) that may be found on buttocks, lower back, and to lesser extent on arms, abdomen, and thighs Skin turgor Test by gently pinching various areas of the skin -Areas over sternum and forehead do experience less of an age-related reduction in turgor and are good areas for turgor assessment Pressure tolerance -Inspecting pressure point after patient has been in the same position for half an hour -If redness is present, patient must be on turning schedule of every half an hour -If redness not present, allow patient to remain in the same position for 1 hour and inspect; if redness is not apparent, increase increments by half an hour up to 2 hours Temperature Obtain gross assessment of skin temp by using back of hands and touching various areas -Note coldness or temperature inequalities between the extremities

Signs of Imminent Death

Bodily functions slow down Nurses need to identify and recognize approach of death symptoms to keep family informed -Gives opportunity to share the last minutes of the patient's life -If family unavailable, a staff member should remain with patient Determine if clergy is desired by the patient and/or family Care of the dying individual and family -Patient not be alone during this period -Even if it appears that patient is unresponsive, he or she should be spoken to and touched Signs and Symptoms -Decline in blood pressure -Rapid, weak pulse -Dyspnea and periods of apnea -Slower or no pupil response to light -Profuse perspiration (lots of sweating) -cold extremities -bladder and bowel incontinence -pallor and mottling of skin -loss of hearing and vision

Commonly used drugs by older adults

Cardiovascular agents -for heart or circulatory system -arrhythmias -blood clots -coronary artery disease -high/low BP -High cholesterol -Heart failure -stroke Antihypertensives -treat high blood pressure -lower blood pressure -some remove extra fluid and salt from body -others relax and widen blood vessels or slow heartbeat Analgesics -relieve pain Antiarthritic agents -treat or prevent joint pain and joint diseases -relief to swelling, tenderness, pain, stiffness, and decreased ROM Sedatives -insomnia -sleep disorders -muscle pain and spasms Tranquilizers -sleep disorders -tension -acute anxiety Laxatives -treat constipation Antacids -neutralize acid in stomach to relieve indigestion and heartburn Many cause confusion, dizziness, falls, F&E imbalances and threaten quality of life Some interact when taken together causing serious adverse effects

Floor coverings (safety)

Carpet Sound absorber Static electricity and cling- due to gait -Have shuffling gait and incomplete toe lift during ambulation -Uncomfortable static electricity -Clinging of slippers and shoe soles to carpeting could cause falls Difficult wheelchair mobility -More plush the carpet is, the more difficult it becomes to roll wheels on its surface Cleaning -Spills are more difficult to clean on a carpeted surface -Even with washable surfaces, discoloration can result Odors; cling to carpet, unpleasant -Cigarette smoke and other odors can cling to carpeting -Urine, vomitus, and other substances demand special deodorizing efforts that may not prove effective Pests reside -Undersurface of carpeting provides wonderful environment in which cockroaches, moths, fleas, and other pests can reside Fall risk -TO benefit, carpeting may be applied to some of the wall surface rather than floor -Provide noise buffer, textural variation, and decor Throw rugs -AVOID!!! Tips: -Tiled floor covering should be laid on wood foundation rather than directly on cement surface for better insulation and cushion -Non-glare surface -Single solid color -Floor treatments that create nonslip surface are useful in bathrooms, kitchens, and areas leading from outside doors

Comfort

Comfort has different meanings for different people -Can be a feeling, relief, physical ease, well being -Taken for granted until threatened Comfort in the holistic sense -A sense of physical, emotional, social, and spiritual peace and well-being Pain and discomfort incidence increases with age

Comforting

Comfort measures Giving patient undivided attention -Regardless of the length of interaction -Pause before coming in contact with patient, take a deep breath, and mentally affirm that you are going to focus on patient during time you are together Listening attentively -Hear what patient has to say -Encourage patient to speak and demonstrate interest through body language and feedback Explaining -Communicate about interventions -Describe procedures, changes, and progress Touching -Gently massage -Hold hand -Touch shoulder Perceiving -Watching for signs that can indicate distress (sighing, tear-filled eyes, flat affect) -Then validate what you are seeing and acquire about their cause ( "Ms. you seem a little distracted today. Is there something you would like to talk about?"

Menopause

Definition of menopause -12 months without a menses (NOTHING! No bleeding, spotting, nothing) -The permanent cessation of menses for at least 1 year -Occurs for most women around the fifth decade of life -A time of important transition in a woman's life that can result in awakening of a new wholeness of body, mind, and spirit Women in their 50s, 60s, and beyond can feel unattractive, unappreciated, and underutilized as a result Menopause marks the entry into a new season of life, characterized by wisdom and groundedness Occurs when estrogen levels fall and reduced number of ovarian follicles lose their ability to respond to gonadotropic hormone stimulation Physical, emotional and cognitive symptoms Physical symptoms -Hot flashes -Fatigue -New onset of migraines -Symptoms of arthritis, fibromyalgia -Heart palpitations, atypical angina -Restless leg syndrome -Vaginal dryness, itchiness -Loss of subcutaneous fat in labia -Insomnia -Decreased metabolic rate, weight gain -Increased fat on stomach and hips -Lower urinary tract symptoms (urinary frequency, stress incontinence, urgency, and nighttime voiding) -Bladder and vaginal infections -Increased risks of osteoporosis, heart disease, and colon cancer Emotional/cognitive symptoms -Moodiness -Depression -Memory problems -Fuzzy thinking -Lack of concentration -Lower tolerance for annoyance -Quick to anger -Greater impatience -Anxiety, restlessness, new onset of panic disorder -Paranoia, psychotic symptoms Management of symptoms effectively important Can enable women to experience this season of life as a positive passage rather than as a distressing detour -Acupuncture -Diet -Foods rich in plant estrogens (apples, beans, carrots, celery, nuts, seeds, soy products, wheat, and whole grains) -Foods rich in boron to increase estrogen retention: asparagus, beans, broccoli, cabbage, peaches, prunes, strawberries, tomatoes -Avoidance of adrenal-stimulating foods: alcohol, caffeine, refined carbs, salt, and sugar -Exercise -Imagery -Mediation -Regular, adequate sleep -Stress management practices -T'ai chi -Vaginal moisturizing agents -Commercial vaginal moisturizing creams (Replens), water-based gels -Herbal salves made with marshmallow root, calendula blossom, comfrey, licorice root, and wild yam -St. John's wort oil -Vitamins and minerals such as calcium, chromium, magnesium, selenium, and vitamins C,D, and E -Yoga Nursing knowledge r/t menopause essential -Menopause is a naturally occuring process, not a disease -Menopause is a gradual process (most women experience perimenopause about 3 to 6 years before menopause. By age 40, most women begin having irregular periods) -Menopause is a multihormone process -Estrogen affects function beyond those of reproduction -Diagnostic blood tests should be done to properly assess menopausal state -HRT carries risks and benefits

Cultural Considerations

Each culture determines own ethical standards -What might be considered ethical practice for some individuals may not be viewed as such by others due to their cultural backgrounds Nurses need to be aware of differences to avoid potential ethical conflicts -Nurse may be a white, Protestant woman born in the United States who holds beliefs shown below. -These beliefs could be acceptable and appreciated by many individuals, they could conflict with beliefs of others Important to remember each individual is different -Not all individuals from the same cultural group may share the same beliefs and practices -Importance of learning about individual preferences Examples: Each individual has right to make own decisions, regardless of their sex and should be empowered to do so -In many Amish, German, Greek, Haitian, Irish, and Puerto Rican families, individuals discuss important decisions with family members and may prefer to have family involved in the decisions -Jewish indivdiuals may seek the advice of a rabbi -Some people may not want to discuss issues and confront decision-making (Many Filipinos, Chinese, and Japanese view discussions of death as taboo) Women are equal to men -In Arab, Iranian, Hindu and some Italian families, it is common for males to assume decision-making roles -Women may yield their decision-making authority to them Prayer is beneficial supplement -Prayer may not be welcomed by patients who are agnostic or atheistic -Even among persons who do believe in prayer, there may be differences in the deity worshipped and method of prayer Right to confidentiality, even from relatives -To individuals who view family involvement in decision-making as natural and preferable, there may be a desire to have health info shared with family

Skin cancer

Early detection improves the prognosis Basal cell Carcinoma MOST COMMON FORM OF SKIN CANCER -More prevalent in fair-skinned, blonde, or red-headed persons with extensive previous skin exposure -Rare in black or dark skin -Men more than women Grows slowly and rarely metastasizes Risk factors -Advanced age -Light exposure to UV radiation from sun -Therapeutic radiation Appearance -Pearly white or waxy papule -Often with visible blood vessels on face, ears, scalp, or neck -May bleed, crust, or form depression in center (giving donut-shaped appearance) Squamous cell carcinoma Arises in squamous cells that are on surface of the skin, the lining of hollow organs of the body, and passages of respiratory and digestive tracts Risk factors -Sun exposure -Exposure to hydrocarbons, arsenic, and radiation can facilitate growth Characteristics -Slow growing -Can metastasize (lower lip is common site of metastasis) -Can develop in scar tissue -Associated with decreased immune system Appearance -Firm, red nodule on face, lower lip, ears, neck, hands or arms, may bleed -Flat lesion with scaly crust on face, ears, neck, hands or arms -New ulceration on pre-existing scar or ulcer -Ulcer or flat, white patch inside mouth -Red, raised patch or ulcerated sore on anus or genitals Melanoma TENDS TO METASTASIZE (SPREAD)! MORE DEADLY if not caught early! Rising incidence in the United States -Probably due to sun exposure Fair skinned individuals are at higher risk for melanomas Incidence increases with age Treatment -Biopsy and excision of cancer and some surrounding tissue -Some recommend removal of all palpably enlarged lymph nodes -Possible chemo -Radiation -Surgery Prognosis -Depends on WHEN DIAGNOSED (teach to inspect themselves; identify moles that demonstrate changes in pigmentation or size. Seek evaluation of suspicious lesions.) -Depends on DEPTH of lesion (rather than type) -If caught early, some can be cured -If spread beyond skin and nearby lymph nodes (metastasis), may not be cured, so prognosis can be poor

Stages of the dying process and nursing interventions

Elisabeth Kubler-Ross's (1969) conceptual framework -Five stages of coping mechanisms with dying -Nurse needs to understand which interventions are most appropriate during each stage -Not all dying persons progress through the stages in an orderly sequence or experience all of the stages First stage: Denial Initial awareness of impending death Deny the reality of the situation -"It isnt true" -"there must be some mistake" Serves several useful purposes -It is a shock absorber after learning the difficult news -Provides opportunity for people to test the certainty of this information -Allows people time to internalize the information and mobilize their defenses May occur at various times throughout an illness; fluctuation -Need is strongest early on -Fluctuate between wanting to discuss their impending death and denying its reality (Accept use of defenses rather than focus on the conflicting messages) Care and interventions during this stage: -Accept dying individual's reactions -Provide opportunity for honest dialogue Second stage: Anger Feeling that nothing is right "Why me?" -Ex: nurses do not answer call light soon enough, food tastes awful, doctors do not know what they are doing, visitors either stay too long or not long enough Difficult for individuals around the dying person -Frequently the victims of displaced anger Unfilled desires and unfinished business -May cause outrage Family may feel guilty, embarrassment, grief, or anger in response to dying person's anger -May not understand why their intentions are misunderstood or their actions unappreciated -Not unusual for them to question whether they are doing things correctly -Help family gain insight into individual's behavior which can relieve their discomfort (it's not personal) --> more supportive relationship Care and interventions during this stage: -Do not respond to anger -Be accepting to individual -Anticipating needs, remembering favorite things, and maintaining pleasant attitude can counterbalance anticipated losses Third stage: Bargaining Postponement of the inevitable Promises in return for an extension of life -Promise to take better care of themselves if the physician initiates aggressive therapy to prolong life Most bargains are made with God and usually kept as secret -May agree to be a better Christian if God lets them live Care and interventions during this stage: -Explore individual's feelings with him or her Fourth stage: Depression Reality of the dying process is emphasized -When patient is hospitalized with increasing frequency and experiences declining functional capacity and more symptoms Many losses can lead to depression -Lifetime savings, pleasurable pastimes, and a normal lifestyle might be gone -Bodily functions and even body parts may be lost -Depression may not benefit from encouragement and reassurances (don't tell them to look at the sunny side) Usually a silent depression -Cheerful words may be far less meaningful to dying individuals than holding their hand or silently sitting with them Interest in prayer and desire for clergy Care and interventions during this stage: -Be with individual -Facilitate clergy-patient relationship -Help family understand the depression (efforts to cheer dying person can hinder) -Family may require reassurance for the helplessness they feel -This type of depression is necessary for individual to approach death in a stage of acceptance Fifth stage: Acceptance Struggling ends and relief ensues Possibility of this being a final rest to gain strength for the long journey Come to terms with death and gain a sense of peace -Not mistaken for happy state; it implies individual has come to terms with death and has found sense of peace -Their silence and withdrawal should not result in isolation from human contact = touching, comforting, and being near the person are valuable Care and interventions during this stage: -Patients may benefit more from nonverbal than verbal communication -Simplify environment (as dying person's circle of interests gradually shrinks) -Family needs a great deal of assistance in learning to understand and support their loved one during this stage A realistic confrontation of impending death does not negate the presence of hope! -Hope commonly permeates all stages of the dying process

Risks for RNs in a supervisory role (supervision of other staff)

Falls under the doctrine of respondeat superior ("let the master answer") If patient is injured by an employee they supervise while employee is working within the scope of the applicable job description, nurses can be liable Permitting unqualified or incompetent persons to deliver care Failure to follow up on delegated tasks Assigning tasks to unqualified staff or incompetent staff Allowing staff to work under conditions with known risks -Being short staffed -Improperly functioning equipment

Psychosocial considerations

Feelings and behavior influence and are influenced by the individual's surroundings Need for privacy and personal space Potential for invasion of privacy and personal space Interventions to provide privacy: -Define specific areas and possessions that are the individuals (this side of the room; this room in the house; this chair, this bed, etc) -Provide privacy areas for periods of solitude (if room not available, arrange furniture to achieve maximum privacy) -Request permission to enter personal space -Allow maximum control over one's space

Definitions of death

Final termination of life Cessation of all vital functions Act or fact of dying United Nations Vital Statistics Division: -Cessation of vital functions without capability of resuscitation Brain death: determined by EEG Somatic death: determined by the absence of cardiac and pulmonary functions Molecular death: Determined by cessation of cellular function In some situations, an individual with a flat EEG still has cardiac and respiratory functions - are they still considered dead?

Influenza

Flu can be serious illness in older adults -70-85% of seasonal flu deaths occur in 65+ age range -50-70% of seasonal flu-related hospitalizations in this age group Older adults (and others) with chronic disease are more likely to have problems from flu-- hospitalization, can be fatal 65+ at greater risk of serious complications from flu -especially 85+ age group!! Immune defenses weaken with age Symptoms -Fever -Headache -Fatigue -Aches -Pains -Cough -Sore throat -Runny or stuffy nose Diagnosis -Rapid influenza diagnostic test (best if tested within 3-4 days of illness onset) Administered vaccine -High dose, designed for 65+ -Contains 4X amount of antigen as regular flu vaccine

Pneumonia rationale

Frequently older adults do not experience chest pain associated with pneumonia to the same degree as younger adults do Their normally lower body temperature can cause an atypical appearance of fever (at lower levels than would occur for younger) By the time symptoms are visible to others, pneumonia can be in advanced stage Older adults do not develop sepsis before other symptoms of pneumonia occur and do not develop lung consolidation rather than secretions Pneumonia is not often linked to exposure to toxins over the lifetime

Confidentiality

HIPAA -Patients have acess to their own medical records -Patients have control over how Personal health Information is used and disclosed -Patients can ask their providers to change incorrect information that they have discovered in their record or to add missing information -Can request that their health information not be shared -Civil and criminal penalties for covered entities that misuse personal health information -Administrative Simplification Compliance Act amended HIPAA to require all claims submitted to Medicare be done so electronically -Unfamiliarity with policies and procedures necessary to protect your patient's privacy; no excuse and the consequences can be dire The minute you put something in the medical record, it stays there. Label EXACTLY what it is - not what you think it is.

Summary for nutrition

Healthy nutritional status important for mental and physical health Nutritional needs for older adults are altered by many factors: -Reduced BMR -Decreased activity -Reduced lean body mass Reduced calories + High quality nutrients Fluid intake risks Recommended fluid intake Common nutritional problems

Additional CV Conditions

Hyperlipidemia Arrhythmias, Dig toxicity, A Fib Peripheral vascular diseases -Arteriosclerosis -Aneurysms -Varicose veins -Venous thromboembolism

Safe medication use for older adults

Important for nurse to understand special considerations for medication use in older adult population Drugs act differently in older adults than in younger adults Require careful dosage adjustment and monitoring Older adults more likely to take more than one medication regularly ---> increases risk of interactions and adverse reactions To minimize risks associated with drug therapy and ensure medications don't create more problems: -Close supervision -Adherence to sound principles of safe drug use are essential

Special risks of cancer for women

Increased risk for ovarian and breast cancer -Genetic factors -Increased age -Women who have first-degree relative (mother, sister, daughter) with breast/ovarian cancer -Other risk factors -Women who had first period before age of 12 years or experienced menopause after 55 years -Women who had first child after 30 years Increased risk for vaginal cancer -Women whose mothers took diethylstilbestrol during pregnancy have increased risk of vaginal cancer Increased risk of ovarian cancer in those who have had colon cancer -Excess estrogen is suspected to contribute to breast cancer

Threats to good nutrition

Indigestion and food intolerance Decreased stomach motility, less gastric secretion, and slower emptying time Nursing interventions -Recommend small frequent meals (rather than 3 large ones) -Avoid or limit fried foods (easier to digest broiled, boiled, or baked food) -Remain upright (High fowlers) for 30 min after meal -Ensure adequate fluid intake & activity to improve motility of food through GI tract Anorexia Related to variety of conditions -Medication side effects -Inactivity -Physical illness -Age-related changes (decreased taste and smell sensations; reduced production of hormone leptin, and gastric changes) Losses and stresses that cause anxiety and depression -Death of loved ones -Loneliness -Financial worries -Living with effects of chronic conditions Need to identify cause -Treatment could consist of high-calorie diet, referral to social programs, tube feeding, hyperalimentation, psychiatric therapy, or medications -Stimulation of appetite can be achieved through use of lemon, pomegranate, and cranberry juice and certain herbs (ginger root, ginseng, peppermint) -Monitor intake and output, weight -Weight loss greater than 5% within a 1-month period and 10% within 6-month period is considered significant Dysphagia (difficulty swallowing) Incidence increases with age Causes -Neuro conditions (such as stroke) -GERD (most common) Nursing interventions -Sit upright when ingesting food or fluids -Allow enough time for eating and swallowing -Ensuring no residual food in mouth before feeding additional food -Small amount in mouth -No talking while eating -Keep suction available -Monitor I&O and body weight -May use thickened liquids -Tilting head to a side and placing food on particular part of tongue may be recommended Constipation Common problem in older adults Causes -Slower peristalsis, -Inactivity -Medication side effects -Decreased fiber and fluids' If oil-based laxatives are used, fat-soluble vitamins (ADEK) can be drained from body, leading to vitamin deficiencies Preventive measures -Fluids -Fruits, veggies -Regular activity -Insoluble fiber will aid peristalsis -Bananas, prunes, carrots, or oatmeal facilitate bowel elimination -Laxatives are last choice (can lead to diarrhea and dehydration) Malnutrition Contributing factors -Loss or decreased sense of taste & smell -Inability to chew adequately -Decreased hunger contractions -Slowed peristalsis -Reduced gastric secretions -Less nutrients absorbed -Adverse effects of meds -social and economic factors Signs of clinical malnutrition -Weight loss greater than 5% in past month or 10% in past 6 months -Weight 10% below or 20% above ideal range -Serum albumin level lower than 3.5 g/100 mL -Hemoglobin level below 12 g/dL -Hematocrit value below 35% Other problems that may indicate malnutrition -Delirium -Depression -Visual disturbances -Dermatitis -Hair loss -Pallor -Delayed wound healing -Lethargy -Fatigue

Breathing exercises

Inhaling -One hand on stomach and other over middle of chest -Patient should inhale to the count of one -Hand over stomach should move outwardly as stomach and diapgrahm move downward -the hand over the chest should not move Exhaling -Expire air to count of 3 -Hand over stomach should be pulled closer to body as stomach and diapgrahm move upward -hand over chest should not move

Aging & Safety risks

Injury rate for older adults occupies the midrange for all groups Older women have higher rate of injuries than any other adult female age group rate of injury among men declines through adult years Significant death rate from accidents exists in older adults Accidents rank as 6th leading cause of death in older adults Falls are leading cause of injury-related deaths Susceptible to infections -Due to age related changes, altered antigen-antibody response, and high prevalence of chronic disease -Pneumonia and influenza are the fourth leading cause of death in older adults Greater incidence of nosocomial infections -Health-care associated infections -Contribute to higher mortality rate from infections Atypical symptomatology -Delayed diagnosis!!! Risks involving use of medications -Altered pharmacokinetics -Self-administration problems -High volume of drugs used -Increased risk for adverse Side effects (dizziness or drowsiness)

Ineffective breathing pattern

Inspiration &/or expiration that does not provide adequate ventilation Administer oxygen at lowest concentration indicated & prescribe respiratory meds Suction airway as needed Elevate HOB (most immediate and least invasive) Encourage slow/deep respirations, use pursed lip technique -Deep breathing exercises several times each day can help improve some age-related changes in lung capacity Monitor pulse ox

Effects of aging on Respiratory health

Less ciliary action Reduction in vital capacity, muscle strength, and endurance -Reduction in vital capacity and increase in residual volume = less air exchange and more air and secretions remaining in the lungs Immobility-- less respiratory activity -Muscles and other tissues near airway may lose ability to keep airways completely open, so airways close easily Thicker secretions Change in ability to protect airway -Decreased cough & laryngeal reflexes = ASPIRATION RISK -When person is unable to protect airway = RISK OF ASPIRATION of foreign material and potential development of a lung abscess (a pus-filled cavity in your lung surrounded by inflamed tissue). Nasal passages accumulate dust and dirt -Hair in nostrils becomes thicker with age and accumulate greater amount of dust and dirty particles -Unless particles are removed and nasal passage is kept patent, may be interference with normal inspiration -Blowing nose and mild manipulation with tissue may adequately rid nostrils of these particles -Cotton-tipped applicator moistened with warm water or saline solution may help loosen them Drier mucous membranes -Reduction in body fluid and reduced fluid intake -Impedes removal of mucus and leads to development of Mucous plugs and infection -Often overlooked in prevention of respiratory problems is significance of a healthy oral cavity Problems with loose teeth -Loose teeth that are infected can break or dislodge -- if aspirated, can cause a lung abscess and infection Relaxed sphincters and slower gastric motility lead to risk of aspiration PO2 (partial pressure of oxygen; reflects the amount of oxygen gas dissolved in the blood) reduced as much as 15% between ages 20 and 80 Loss of elasticity and increased rigidity -Lungs become smaller in size and weight with age -Elastic recoil of the lungs during expiration is decreased because of less elastic collagen and elastin -Alveoli are less elastic, develop fibrous tissue, contain fewer functional capillaries, and have less surface area --> reduces gas exchange Decreased ciliary action Forced expiratory volume reduced Blunting of cough and laryngeal reflexes -The trachea stiffens due to calcification of its cartilage --> coughing is reduced due to blunting of laryngeal and coughing reflexes -Gag reflex is weaker due to reduced number of nerve endings in larynx By age 90 years, approximately 50% increase in residual capacity Alveoli fewer in number and larger in size Thoracic muscles more rigid Lack of basilar inflation Less lung expansion Increased anterior-posterior diameter of chest Kyphosis -Loss of skeletal muscle strength in thorax and diaphragm, combined with loss of resilient force that holds the thorax in a slightly contracted position, contributes to slight kyphosis (hunching of the back.) -Barrel chest seen in many older adults

Aging and Risks to Adequate Respiration (table)

Less effective gas exchange Reduced elastic recoil of lungs during expiration Ineffective air exchange Increase in residual capacity Reduced airway clearance Decrease in maximum breathing capacity Less effective gas exchange Hyperinflation of lung apices and underinflation of lung bases Easily fatigued related to decreased respiratory efficiency Reduced number and elasticity of alveoli Poor airway clearance Calcification of tracheal and laryngeal cartilage Increased potential for infection Decrease in vital capacity Increased potential for infection Reduced ciliary activity Increased diameter of bronchioles and alveolar ducts Loss of skeletal muscle strength in thorax and diaphragm Increased rigidity of thoracic muscles and ribs Increased diameter of anteroposterior chest Less efficient cough response

Effects of Aging on the integumentary System

Loss of thickness, elasticity, vascularity, and strength -Delays healing process -Increases risk of skin tears -Bruising -Reduction in melanocytes -Pressure injury -Skin infections Increase in senile lentigines (AGE SPOTS) -Brown-pigmented spots Loss of subcutaneous tissue -Causing wrinkling -Sagging of skin -Can affect self-esteem, temperature control, drug efficacy Loss of hair follicles -Thinning -Graying Increased hair density in nose and ears -More in men, which can clog external ear canals & impair hearing Thicker nails -With longitudinal lines Decreased sebaceous and sweat gland activity -Affects thermoregulation & decreases sweating Higher incidence skin growths -Benign and malignant growths Negative effect on body image, self concept, reactions from others, socialization -Weathered appearance due to exposure to sun, wind, and chemicals

Pruritus (skin condition)

MOST COMMON DERMATOLOGIC PROBLEM AMONG OLDER ADULTS! Causes Any circumstances that dries the person's skin -Excessive bathing -Dry heat -Atopic dermatitis -very dry skin -Kidney disease -Diabetes mellitus -Other medical conditions Potential for skin breakdown and infection -If not corrected, itching may cause traumatizing scratching --> leads to breakage and infection Assess for underlying cause and treat -essential! -Careful assessment to assure conditions, such as scabies, that demand special precautions are not present Treatment -Bath oils -Moisturizing lotions -Massage -Vitamin-rich diet (dietary changes!!!) -Prescribed medications (remember BEERS list); Topical application of zinc oxide is effective in controlling itching -Topical antihistamines!!! and steroids for relief

Summary of respiratory health problems & affects in older adults

Maximum function of respiratory system declines Greater risk for developing pneumonia after bacterial or viral infections Encourage vaccines- influenzas and pneumococcal Physiologic changes -Enlargement and rigidity of chest wall -Airway collapse Expected signs or symptoms -Poorer expansion with less efficient exchange -Shallower breathing -Less effective cough

Examples of medications

Mild pain ACETAMINOPHEN - MOST COMMONLY USED Then NSAIDs- ibuprofen Mild to moderate pain Weak, then stronger opioids Codeine --> hydrocodone --> oxycodone --> tramadol Severe pain -Morphine and fentanyl patches CONTRAINDICATED FOR OLDER PEOPLE!! Pentazocine -High risk of causing delirium, seizures, and cardiac and CNS toxicity

Key points for cancer

More than half of the persons diagnosed with cancer are over age 65 The increase incidence of cancer with age could result from age-related changes that reduce the ability to resist the disease or prolonged exposure to carcinogens Environmental exposure to secondhand smoke increases risk of lung cancer in nonsmokers Tanning today can increase risk of cancer when older

Importance of environment to health and wellness

Micro-environment Immediate surroundings (furnishings, lighting, room temperature, sounds) -Older adults spend greater time in their homes or bedroom of a facility -Focus on microenvironment because it can be more easily manipulated and realizes more immediate benefits Macro-environment Elements in larger world (weather, pollution, traffic, natural resources) The environment should promote continued development, stimulation, and satisfaction to enhance well-being -Must have various levels of needs met within their surroundings Environmental needs and Maslow's theory (table) Higher level satisfaction cannot be achieved unless lower level needs are fulfilled Physiological needs -Shelter -Adequate ventilation -Room temperature about 75 degrees F -Functioning utilities and appliances -Pest control Security -Haven from external threats -Ability to safeguard personal possessions -Adequate lighting -Locks -Smoke detectors -Alarms Love -A place one derives pleasure from being -Familiar and comfortable furniture -Favorite objects -Attractive Trust -A niche in which one can feel confident -Control over lifestyle -Consistent layout/furnishings/temperature/lighting Self-esteem A home one can be proud of and that can act as a status symbol -Includes elegant decor and reflection of personal tastes and interests Self-actualization -Space that promotes the realization of all potential, inspiring objects -Beautiful grounds -Relaxation aids SO..... -They do not think to install free smoke detector is important when there are rodents in apartment -They refuse to have their house remodeled because it will make them look too affluent in a high-crime neighborhood and be target for burglary -Remain socially isolated rather than invite guests to a house perceived as shabby -They are unwilling to engage in creative arts and crafts if they are adjusting to a new and unfamiliar residence

Ethical Dilemmas facing nurses caring for older adults

Most clinical situations not simple, clear-cut ethical decisions -Conflicts with nurses' values -External systems affecting decisions -Conflicts with rights of patient and nurses' responsibility

Analgesics in older adults

NSAIDs widely used due to low cost and effectiveness, however, can be sensitive to effects of aspirin + SEs Aspirin -GI bleeding -Iron deficiency anemia -Gastric irritation Acetaminophen -Popular and used often for mild to moderate pain. -Not anti-inflammatory, but often recommended for initial treatment of osteoarthritis -Do not exceed 4000 mg daily; could result in irreversible hepatic necrosis Short-acting opioids Codeine, fentanyl, meperidine, morphine, oxycodone -Used for mild to moderate pain Use with caution due to risk of adverse side effects: -respiratory depression -Constipation -N/V -Sedation -Lethargy -Weakness -Risk of falls -Confusion -Dependency -Older men may urinary retention if they have prostatic hypertrophy or renal impairment

An integrative approach to pain management

Need for an individualized and comprehensive pain management plan Identify underlying causes for pain Goals should be: SMART -Realistic -Specific -Achievable New or worsening pain -Important to consider poor positioning, posture, inactivity, emotional issues, and adverse drug reactions Common components of pain management plans include: -Complementary therapies -Dietary changes -Medications -Comforting nursing care

Age-related changes and sexual activity/response

Older adults are physically able to remain sexually active Age-related changes do have an impact on sexual function -There is a decrease in sexual responsiveness and a reduction in the frequency of orgasm -Older men are slower to erect, mount, and ejaculate -Older women may experience dyspareunia (painful intercourse) as a reuslt of less lubrication, decreased distensibility, and thinning of vaginal walls -Many older women gain a new interest in sex, possibly because they no longer have to fear an unwanted pregnancy or because they have more time and privacy with their children grown and gone Important to identify barriers to sexual activity Physical, emotional, and social variables impact old persons availability to remain sexually active: -Partner availability -Chronic illness -Surgery -Medications -Negative attitudes from society -Fear of losing sexual abilities -Concerns about body image -Relationship issues -Misconceptions by older adults KEY CONCEPT: -The unavailability of a partner, ageism, changes in body image, boredom, misconceptions, physical conditions, medications, and cognitive impairments are among the factors that can interfere with sexual fulfillment in later life

Older Boomers views on sex

Older boomers (born in the late 40s) View sex differently than previous generations Enjoyed sexual expression as young adults Value warmth, caring, security & a stable relationship Grew into adulthood with birth control pills + society that held a more liberal outlook on sex Helped open the door for gays, lesbians, and transsexuals

Screening tools for sexuality

PLISSIT model Used to help assess older adult's sexuality P: Permission -Obtain permission from the patient to initiate sexual discussion LI: Limited Information -Provide the limited information necessary to dispel any misinformation the patient may have and to help the patient function sexually SS: Specific Suggestions -Offer specific suggestions to address the sexual issues of the patient IT: Intensive Therapy -If necessary, arrange for intensive therapy to help the patient deal with specific sexual issues CDC (5 P's) Helps you remember major aspects of a sexual history 1. Partners 2. Practices 3. Protection 4. Past history 5. Pregnancy

Nursing considerations for older adults with cancer

Patient education -Warning signs CAUTION US Increase awareness of measures to prevent cancer Understanding of warning signs of cancer Self-examination Cancer screening tests Potential S&S -Thickening or lump in body -Weight gain or loss with no known reason -Feeling weak or very tired -Unusual bleeding or discharge -Hoarseness or cough that does not go away -Changes in bowel or bladder habits -Discomfort after eating -Difficulty in swallowing Most often, these potential symptoms are not due to cancer; may be caused by non-cancerous (benign) tumors or other problems. DON'T WAIT TO FEEL PAIN! In it's early stages, cancer usually doesn't cause pain.

Pain: A Complex Phenomenon

Pain is the greatest threat to comfort Definition of pain: American Pain Society -An unpleasant sensory and emotional experience associated with actual or potential tissue damage (implies there had to be objective cause for pain) -Now accepted that pain is subjective; Relies on patient's perception and report Prevalence of pain in older adults -People over age 65 are more likely to experience pain than younger adults -50% experience some degree of pain daily -Difficulty in determining accuracy of pain in the older adult (some underreport it; some overreport it) Pain as a holistic stressor -Affecting physical, emotional, and spiritual well being Types of pain Classified according to its pathophysiologic mechanism: Tissue damage causes nociceptive or neuropathic pain. Nociceptive Caused when nerve endings (called nociceptors) are irritated -Dull or sharp aching pain -Can be mild to severe EX: Stub your toe, burn yourself, twist ankle Responds well to analgesics, anti-inflammatory needs Originates from mechanical, thermal, or chemical stimuli found in muscles, joints, fasciae and other deep structures Somatic -Bone and soft tissue masses -Pain is localized and described as throbbing or aching EXAMPLES: -bone fractures -strained muscles -skin cuts, scrapes -joint pain Visceral -Originates from internal organs of main body cavities -Thorax, abdomen, pelvis -Often poorly localized and may feel like a vague, deep ache, sometimes cramping or colicky in nature -Frequently is referred to back -Deep and aching, can cause generalized or referred pain EXAMPLES: -bladder infection -constipation -Abdominal pain (from IBS for example) -damage to core muscles or abdominal wall Neuropathic Type of pain associated with neuropathies -A malfunction of the nervous system due to injury or illness -Pain can be intense, sharp, shocking, or shooting, BURNING!! -Can often be managed with neurostimulation -Can be due to nerve degeneration, pressure, inflammation, or infection (shingles) -Can be referred to where that nerve would normally supply Examples: -Pain from a slipped disc of L5 spinal nerve and producing pain down leg to outside shin and big toe - phantom limb pain -carpal tunnel syndrome Also classified according to onset: Acute Associated with physiological response to actual tissue damage AKA warning pain (discomfort or signal that alerts you something is wrong in body) -Abrupt onset -Can be severe -Lasts short time Usually subsides as underlying problem is treated Early acute pain management may hasten recovery of causative problem and reduce length of treatment (& cost) Chronic Pain state that persists beyond time expected for an injury to heal -Pain associated with chronic pathology causing continuing pain for months or years -Persistent pain May be associated with long-term incurable or intractable medical condition or disease Pain perception Perception of pain varies among older adults Decreased or increased sensitivity? Decreased transmission of stimuli? NOT AN INEVITABLE PART OF AGING!! Effects of unrelieved pain Complications of unrelieved pain -Impaired quality of life -Limited movement, limitations in performing ADLs -Poor appetite, weight loss -Depression, hopelessness -Sleep disruption -Spiritual distress KEY CONCEPT: The impact of aging on pain perception and tolerance is not fully understood; therefore, the nurse must try to assess and understand each patient's unique pain experience

Assessing nutritional status and hydration in older adults

Physical, mental, and socioeconomic factors affect nutritional status in later life Regular nutritional assessment is essential -Because physical, mental, and socioeconomic factors can change, regular assessment is necessary Collaborative efforts for assessment -Physician -Nurse -Nutritionist -Social worker See assessment guide: Nutritional status Inspect hair; hair loss or brittleness can be associated with malnutrition Inspect skin - persistent "goose bumps" = vitamin B6 deficiency, pallor (anemia), purpura (vitamin C deficiency), brownish pigmentation (niacin deficiency) Test skin turgor; tends to be best in areas over forehead and sternum (preferred areas to test) Note muscle tone, strength, movement. Muscle weakness can be associated with vitamin and mineral deficiencies Inspect eyes (Vitamin A deficiency) Inspect oral cavity; Note dryness (dehydration), lesions, condition of the tongue, breath odor, and condition of teeth or dentures Ask about S/S -sore tongue -indigestion -diarrhea -constipation -food distate -weakness -muscle cramps -burning sensations -dizziness -drowsiness -bone pain -sore joints -recurrent boils -dyspnea -dysphagia -anorexia -appetite changes

Noise control (safety)

Physiologic and emotional effects of sound Sounds can create difficulties for older adults Effect of environmental sounds -Can cause stress with physical and emotional symptoms Noise control begins with the design of the building -Careful landscaping and walls can buffer outdoor noise -Acoustical ceilings, drapes, and carpeting (also useful on walls) are helpful Appliance and equipment maintenance Radios and TVs should not be playing when no one is listening; if one person needs a louder volume, earphones for that individual In institutional settings, individual pocket pagers are less disruptive than intercoms and paging systems

Nursing considerations (Cardiovascular)

Prevention Education, counseling, coaching, and rehabilitative/restorative activities facilitate prevention on three levels: Primary -To prevent disease from developing in healthy older adults Secondary -To strengthen abilities of persons who are diagnosed with disease to avoid complications & worsening of conditions and achieve maximum health and function Tertiary -To maximize capabilities through rehab and restorative efforts so disease doesn't create additional problems Keeping the patient informed Full explanations and reinforcement are necessary for teaching about diagnosis and treatment -Sensory deficits, anxiety, poor memory, and illness Opportunities to ask questions and discuss concerns Preventing complications Edema may result in skin breakdown -Frequent position changes -Maintain proper body alignment -Avoid dependent positions (legs dangling off side of bed) -Avoid constricting clothing -Protect and pad if patient is on stretcher or exam table for long time -Maintain fluid balance; monitor I&O; daily weights, IV fluids -Monitor VS -Oxygen as prescribed, monitor for hypoxia (restless, irritable, dyspneic), carbon dioxide narcosis -Meet nutritional needs -Prevent constipation Promoting Circulation -Monitor for usual BP -Frequent position changes, prevent sources of pressure points on body -Encourage activity, no dangling of extremity -Prevent hypothermia, maintain body warmth Providing Foot Care People with peripheral vascular disease must pay special attention to feet -Bathe and inspect daily -Avoid injury -Prompt attention for any lesions Interventions to prevent injury to the feet -Well fitting shoes -air feet after wearing -avoid colored socks -change socks regularly -keep feet warm -no direct application of heat to feet Promoting Normality -Consideration of the impact of cardiovascular function on sexuality -Patients often do not want to discuss this subject with HCP -Nursing interventions that include teaching -Need for relaxation and rest -Considerations of stressors

General considerations for skin conditions

Promote normalcy -Support client -Skin conditions can cause client to become isolated and avoided -Promote socialization Support use of alternative therapies and remedies once cleared by PCP Various herbs used to treat skin problems -Creams, lotions, shampoos containing aloe, chamomile, and other plant products -Aloe vera has emollient properites (Treating minor cuts and burns) -external application of chamomile extract used for skin inflammation -Witch hazel applied externally for treatment of bruises and swelling Essential oils for prevention and treatment -Thyme oil as antiseptic -Thyme linalool and roosewood oil for topical acne -Rosemary oil for cell regeneration -Oils of basil, cinnamon, garlic, lavendar, lemon, sage, savory, and thyme for insect bites or stings -Topical application of peppermint oil can have anti-inflammatory effect and speed healing of wounds and mild burns Homeopathic and naturopathic remedies -Acupuncture -Biofeedback -Guided imagery -Relaxation exercises Nutritional supplements: -Zinc -Magnesium -Essential fatty acids -Vitamins A, B complex, B6, E Encourage proper hygiene

Ineffective breathing pattern rationale

RAISING THE HEAD OF THE BED IS THE MOST IMMEDIATE, EFFECTIVE INTERVENTION!! The nurse will need to receive an order from the provider for oxygen Preventing infection and keeping nasal passages patent are not going to help the client who is experience respiratory distress

Nutritional needs of older adults

Required amount of specific nutrients varies over a lifetime -Older body has less lean body mass and relative increase in adipose (fat) tissue -Fat tissue metabolizes more slowly than does lean tissue and does not burn calories as quickly -Basal metabolic rate declines 2% of each decade of life after age 25 -Activity level for most older adults is usually lower Older adults have a reduced need for calories BMR declines about 2% for each decade of life -Contributes to weight increase with same caloric intake Reduction in calories is recommended beginning in the fourth decade of life Also need to monitor the quality of caloric intake Choose nutrient- dense foods -Dairy: low-fat milk, yogurt, cheese -Fruits: oranges, raisins, berries, melons -Vegetables: broccoli, carrots, kale -Grains: oats, brown rice, barely, buckwheat, quinoa, whole weat -Protein: Tofu, beans and lentils, seeds, nuts, eggs, lean meats, poultry (without skin), fish Low protein intake, with high caloric and sugar intake --> increases risk of cognitive impairment in late life Harris-Benedict equation - resting energy expenditure -considers age and BMR -Resulting number represents number of calories need to be consumed daily to maintain current body weight with no exercise expenditure Limit dietary fat intake to less than 30% of daily caloric intake Role of fiber in the diet Soluble fiber Oats and pectin -Helps lower serum cholesterol -Improve glucose tolerance in diabetics -Prevent obesity, cardiovascular disease, colorectal cancer Insoluble fiber Found in grains and many vegetables and fruits -Promotes bowel function Reduce simple carbs, increase complex carbs Provide important sources of energy and fiber -Decreased ability to maintain regular blood glucose level --> reduced carb intake -High carbohydrate diet stimulate high release of insulin --> hypoglycemia --> first present as confused state -Complex carbs help lower cholesterol -Good source of vitamins, minerals Protein requirements -at least 1 g of protein per kg of body weight -Important for wound healing -Cell renewal -Maintain enzyme systems -20 to 30% of daily caloric intake derived from protein Absorption of calcium decreases with age Important to maintain healthy musculoskeletal system and promote proper functioning of blood clotting Good intake of vitamin D and magnesium facilitates calcium absorption -Malabsorption -If postmenopausal or over age 65 years, 1200 mg/D Fruit and vegetable intake -At least 5 servings daily

Prevention and screening for cancer

Review of risk factors leads to identification of preventive measures Healthy lifestyle factors to minimize risks Health education and counseling Screening measures will improve outcomes -Mammogram and clinical breast exam every 2 years until age 75 -Screening for colorectal cancer until age 75 Need for early detection

Safety of older adults introduction

Safety is a major concern for older adults older people risks same as any other adult, but greater due to internal and external factors -Age-related factors reduce their capacity to protect themselves -Increased vulnerability to safety hazards Nursing assessment should include review of risks to safety Interventions are necessary to address threats to safety

Supporting nursing staff with end-of-life experiences

Staff caring for the dying have their own feelings regarding the death/dying experience Difficulty realizing one's own mortality Experience with death may be limited Death may be viewed as a dissatisfying failure Nurses may also experience the stages of the dying process Staff working with dying patients need support Nurses need to explore their own reactions to death experiences Acknowledgement of feelings -And when they interfere with a therapeutic nurse-patient relationship -Nursing staff can retreat from a situation that is not therapeutic either for them or for the patient Resource people available to assist nurses through providing support -Use of thanatologists, hospice staff, and other resource people Nursing staff should be encouraged to express their own feelings about patients' deaths

Pain Assessment Instruments

Standardized methods for assessment of pain For self reporting: Numeric rating scale -To asks patient to rate pain on scale from 0 to 10. -Important to assess persons ability to understand and follow directions Visual Analog Scale -Uses horizontal line with "no pain" on left end and "pain as bad as it possibly can be" on right end -Patient indicates where his or her pain falls on scale -Modified version of this tool uses faces Pain Thermometer -assesses pain by asking patients to indicate the intensity or severity of their pain on a diagram of a thermometer. -It is a version of a verbal descriptor scale that visually represents increasing degrees of pain along the thermometer FACES pain scale -The Wong-Baker Faces Pain Rating Scale -The scale shows a series of faces ranging from a happy face at 0, or "no hurt", to a crying face at 10, which represents "hurts like the worst pain imaginable

Nutritional supplements

Supplements can compensate for inadequate intake of nutrients Nutrients commonly deficient in older adults -Niacin -Riboflavin -Thiamine -Vitamin B6 -Vitamin C -Vitamin D Excess of supplements -Cause adverse effects --> use as directed -Excess calcium consumption (in excess of 2,000 mg) can lead to kidney stones and increased risk of cancer -If calcium supplements used, no more than 500 mg should be taken at one time Nursing assessment -Include review of supplements ingested -Teach to avoid excess + REVIEW WITH PCP

True or false: Nurses can be protected from malpractice suits if they are following the accepted standard of care

TRUE!

Altered Pharmacokinetics: Excretion

The kidneys are a major route for excretion of drugs from the body Drugs also eliminated from feces, exhalation, perspirations, and saliva Reduced efficiency of kidneys -Less number of nephrons -Reduced GFR; decreased blood flow to the kidneys = Drugs not filtered from bloodstream = present in body longer Effects of age-related changes in the liver may affect metabolism -Liver size & function decreases -Less hepatic blood flow = metabolism of many drugs are affected Changes in renal and liver function contribute significantly to the changes in pharmacokinetics that are common in older adults

Summary of safety in older adults

The normal physiologic changes of aging, increased incidence of chronic illness, increased use of meds, & sensory or cognitive changes places aging population at increased risk for injury Age-related factors reduce their capacity to protect themselves Most common injuries experienced by older adults: -Falls -Burns -Poisoning -Auto accidents Are at increased vulnerability to safety hazards Risk for injury increases dramatically when older adults are exposed to multiple environmental hazards Recognize atypical presentations of illness in older adults Altered pharmacokinetics -Decreased liver and kidney function Physical, cognitive limitations may increase safety risks -Slower response and reaction times as a safety hazard with slower movement, poor coordination, poor judgment Nurses can help older adults recognize their risk factors, by planning coping strategies to promote safety, and modifying environment to minimize likelihood of injury

Changes in the body: Cardiovascular system

These changes are typically gradual and become most apparent when faced with unusual physiological stress, such as heightened activity or an infection Heart size unchanged (in absence of pathology) Valves thick & rigid -Due to sclerosis and fibrosis Heart muscle loses efficiency -Reduced cardiac output under physiologic stress -Loses contractile strength --> causing reduction in cardiac output when demands on heart are increased Reduced elasticity of blood vessels -Calcification Increased peripheral resistance -Hypertension is NOT normal part of aging -As resistance increases, blood pressure increases and flow decreases -Less sensitive to baroreceptor regulation of blood pressure

DNR (Do not resuscitate) orders

This is a medical order -Must be written and signed on the physician's order sheet to be valid -DNR placed on the care plan or a special symbol at patient's bedside is not legal without medical order Consent for DNR must be obtained -If patient is unable to consent, family consent should be sought Every agency should develop DNR policy to guide staff Unless an order specifically states that the patient should not be resuscitated, failure to attempt to save that person's life could be viewed as NEGLIGENCE MUST BE WRITTEN IN HOSPITAL!!!!!!!!!!! IN HOSPITAL DNR!!!

Lifestyle modifications for cardiovascular health

To lower risk of high blood pressure Keep healthy weight -Being overweight adds to your risk of high blood pressure Exercise every day -Moderate exercise can lower risk -Set some goals for yourself so that you can exercise safely and work way up to exercising at least 30 minutes a day most days of the week -Check with doctor before starting an exercise plan if they have any health problems that are not being treated Eat a healthy diet -Diet rich in fruits, vegetables, whole grains, and low-fat dairy products Cut down on salt -Most salt comes from processed food (soup and baked goods) -A low-salt diet might lower risk Drink less alcohol -Most men should not have more than two drinks a day -Most women should not have more than one drink a day Don't smoke -QUIT Get a good night's sleep -Tell doctor if you snore or sound like you stop breathing for moments when you sleep -Treating sleep apnea and getting good night's sleep can lower BP

Lighting (safety)

Use several diffuse lighting sources -Rather than a few bright ones Do not use fluorescent lighting -Causes eye strain and glare Control bright lights and direct sunlight -assess room for glare and eliminate -Filter sunlight with sheer curtains -Assess lighting from a seated position because it can appear differently from chair or bed level than standing position Use night-lights to promote visibility and orientation -soft red night light can help improve night vision Use natural light to maintain body rhythms -Which, in turn, influence body temperature, sleep cycles, hormone production, and other functions

Physiologic Changes in females- Menopause

Vaginal wall drying and atrophy Shortening and narrowing of vagina -Can cause dyspareunia (painful intercourse) Decreased vaginal secretions Reduction in size of clitoris Decreased sexual drive = more time for stimulation Sexual self-image impacted -Wrinkles -Sagging breasts -May feel less desirable Lack of interest, loss of physical stamina, or decrease inability to perform r/t underlying condition can compound physiologic changes -Low libido

Vascular Lesions

Varicose veins -Weakened walls of veins reduce the ability of veins to respond to increased venous pressure Weakened vessel walls cause varicose veins. Poor venous return and congestion that result lead to edema of lower extremities which leads to poor tissue nutrition. Poorly nourished legs accumulate debris, inadequately carried away with venous return, the legs gain pigmented, cracked, and exudative appearance Can result in Stasis Dermatitis --> can result in leg ulcers (stasis ulcers) from scratching, irritation, or other trauma (tight elastic-band stockings)

Seborrheic Keratosis (skin condition)

Waxy or wart-like growth Ranges in color from light tan to brown or black. Round or oval shaped Pasted on look, flat or slightly elevated with scaly surface Ranges in size from very small to more than 1 inch across; small as pinhead or large as a quarter May itch!! Increase in size and number with age Areas of the body affected -Face -Chest -Shoulders -Back -In oily areas of trunk, face, and neck these lesions appear dark and oily -In less oily areas, they are dry in appearance and light color Will NOT have swelling or redness around their base!! Treatment Lesions are benign (not cancerous) (but differentiate from precancerous lesions) -Abrasive activity with gauze pad containing oil will remove small seborrheic keratoses -Larger, raised lesions removed by freezing agents or by a curettage and cauterization procedure

Elements of Informed Consent

1. Written description of the procedure and its purpose 2. Explanation by the person performing the procedure 3. Alternatives to the procedure 4. Expected consequences and risks 5. Signature of the patient, witnessed, and dated -TIME OF THE SIGNATURE! -Has to be dated, timed, and signed. 6. Patient has right to refuse to give consent for procedure -Have patient sign release form Procedure performed without consent = BATTERY Written informed consent includes a description of: -the procedure -it's purpose -alternatives to procedure -expected consequences -risks

Constipation at end-of-life

A source of additional discomfort Prevention as a goal for care! Causes: -Reduced food and fluid intake -Inactivity -Effects of medication Interventions: -Promote regular bowel movements (patterns should be recorded and assessed) -Increasing activity -Intake of fluids and fibers -Laxatives administered on a regular schedule -Prevent impaction and recognize when occurs! (what appears to be diarrhea may actually be seepage of liquid wastes around fecal impaction)

Keratosis (skin condition)

AKA Actinic or solar keratosis Small, rough, dry or scaly patch, light-colored lesions, flat to slightly raised Color ranging from pink to red to brown or flesh-colored. Usually gray or brown on exposed areas of the skin -Formation of cutaneous horn with slightly reddened and swollen base Itching or burning in affected area, may ooze or bleed Precancerous lesions Treatment -Cryotherapy (cold therapy; freezing agents and acids) is common -Dermabrasion (Scraping off) -Surgical removal or laser therapy Prevention Sun safety -Limit time in sun -Use sunscreen -Cover up -Avoid tanning beds -Check skin regularly The main difference from Seborrheic Keratosis is that actinic keratosis has the potential of becoming cancerous.

Cardiovascular terms to know

Arrhythmia -Abnormal heart rate or rhythm Atherosclerosis -Hardening and narrowing of arteries due to plaque buildup in vessel walls Hypertension -Consistent blood pressure reading greater than 140 systolic and greater 90 diastolic Physical deconditioning -Decline in cardiovascular function due to physical inactivity Postural hypotension -Decline in systolic blood pressure of 20 mm Hg or more after rising and standing for 1 minute Orthostatic vital signs -Obtaining patient's BP and HR when they are supine, sitting, and standing

Identify safety hazards for older adults in the average bathroom

Adequately lighted hallways and stairways Floor surface even, easy to clean, requiring no wax, free of loose scatter rugs and deep-pile carpets Bathtub or shower with nonslip surface, safety rails, no electrical outlets nearby Hot water temperature less than 110 F Faucet handles easy to operate, clearly marked hot and cold

Which statement is true related to the use of restraints? A. Geriatric chairs are not restraints B. Alternatives to restraints should be used whenever possible C. Physician's orders for restraints are not required in long-term care facilities D. The Omnibus Budget Reconciliation Act (OBRA) heightened the impact of restraints in acute care settings

B. Alternatives to restraints should be used whenever possible Alternatives to restraints should be used whenever possible to promote safe and effective care Geriatric chairs are considered restraints Physician orders are required for restraint use in any health care settings OBRA increased awareness of restraint use in long-term care

Promoting the safe use of drugs

Beers' Criteria -Identification of drugs that carry high risks for older adults, age 65 and older regardless of where they reside (ambulatory, acute, and institutional settings) or receive care (except hospice and palliative care) -Determine if prescribed or OTC meds are on Beers list, especially with new onset delirium or change in mental status -Guides provider to avoid potentially inappropriate meds and promotes use of alternative meds List has been divided into primary groups: -Meds to avoid for many or most adults -Meds for older adults with specific diseases or syndromes to avoid -Meds to be used with caution -Meds to avoid or dosage of which should be adjusted based on individuals kidney function Major drugs of concern -Anticholinergics (cognitive impairment, BPH) -Tricyclic antidepressants (TCAs) [arrhythmias] -Antipsychotics (syncope and falls) -Barbiturates (except when used as anticonvulsants)[cognitive impairment] -Benzodiazepines Reviewing Necessity and Effectiveness of Prescribed Drugs In an effort to minimize polypharmacy in older adults -Associated with increase risk of adverse outcomes Why is the drug ordered? -Is it really needed? -Can warm milk and back rub eliminate need for sedative? -Did patient have bowel movement this morning and not need the laxative? Medication may be used because it has been prescribed for years and no one has considered its discontinuation Is the smallest possible dosage ordered? -Older adults usually require lower dosages of most medications because of delayed time for excretion of substance Is the patient allergic to drug? -Physician may overlook a known allergy Can drug interact with other drug? -Herbs, nutritional supplements that are being used? Are there any special instructions accompanying the drugs administration? -Some drugs given on empty stomach and other drugs given with meal -Certain times of day may be better for some drugs Is the most effective route of administration being used? -A person who can't swallow a large tablet may do better with liquid form for example Regular review of a drug's ongoing necessity and effectiveness is essential Safe and effective administration Oral medications -Most common route -Dry oral mucous membrane (common and can prevent capsules and tablets from being swallowed) -Ensure proper oral hygiene -Ample fluids for assistance with swallowing and mobility -Proper positioning -Examining oral cavity after administration -Some older people may not even be aware that a tablet is stuck to the roof of their dentures or under their tongue Enteric-coated and sustained-release tablets -DONT CRUSH -Capsules are not to be broken open and mixed -Older peoples taste buds for sweetness are lost long before those for sourness and bitterness -Oral hygiene after administration of oral drugs prevents unpleasant aftertaste Suppositories -Decreased circulation in lower bowel and vagina -Decreased temperature in older adult -So may take longer to melt -effort to ensure suppository is not expelled Intramuscular and subcutaneous administration -For immediate results -Upper, outer quadrant of the buttocks is best site for IM injections -Alternate sites -Monitor sites -Do not administer in immobile limb d/t slower rate of absorption -Older person will bleed or ooze after injection because of decreased tissue elasticity; small pressure bandage may be helpful -Reduced subcutaneous sensation in older persons or absence of sensation (that experienced with stroke) may prevent person from being aware of complication at injection site Intravenous administration Need to be alert to amount of fluid in which drug is administered -Risk for overload d/t cardiac and renal function declining Symptoms for circulatory overload: -Elevated BP -Increased respirations -Coughing -SOB -symptoms associated with pulmonary edema -Monitor intake and output, body weight, and specific gravity Decreased sensation may mask any potential complications Patient teaching Assess risk for medication errors -Use of multiple medications -Cognitive impairment -Hearing deficits -Arthritic or weak hands -History of noncompliance with medical care -Lack of knowledge regarding medications -Limited finances -Illiteracy -Lack of support system -History of inappropriate self-medication -Presence of expired or borrowed medications in home Detailed description of medications Interventions for people who may have difficulty with medications -Detailed written description should be given to older people and caregivers that outlines drugs name, dosage schedule, route of administration, action, special precautions, incompatible foods or drugs, and adverse reactions -Color-coded dosage schedule can assist with visual deficits or illiterate -Med labels with large print and caps that can be easily removed by weak or arthritic hands Close monitoring -Review patients medication schedule and new symptoms for close monitoring

C.A.U.T.I.O.N. U.S. (warning signals of cancer)

C: Change in bowel or bladder habits A: A sore throat that does not heal U: Unusual bleeding or discharge T: Thickening or lump in the breast or elsewhere I: Indigestion and difficulty swallowing O: Obvious change in wart or mole N: Nagging cough or hoarseness of voice U: Unexplained anemia S: Sudden weight loss

Hypotension (Cardiovascular)

Can be a sign of an underlying problem -May be related to vasoactive medications -BR due to illness -Injury -Dehydration -Post-prandial (after a meal); can be prevented by drinking a caffeinated beverage after the meal. If new onset, review med regimen Teach safety measures Orthostatic hypotension -MAJOR RISK Factor for syncope and falls in older adults

Prevalence and risks of cancer in older adult population

Cancer is the SECOND leading cause of death in persons age 65 or older -Cancer occurs with great frequency in older adults Probability of developing cancer increases with age -Common types of cancer: lung cancer, breast cancer, prostate cancer Role of the gerontological nurse Prevention -Important to recognize potential for numerous other forms of cancer Diagnosis -Presence of cancer itself reveals presence of immune deficiency -Cancer cells are normally detected by an immune system and eliminated after being recognized as abnormal -It is only when the immune system fails to carry out this function that cancer occurs Treatment -Cancer and cancer treatment can cause additional immune deficits

COPD

COPD represents a group of diseases including a form of asthma, chronic bronchitis, and emphysema. Grouped together because of their common outcome of obstruction airflow Incidence of COPD is higher in women and in smokers Chronic Bronchitis Many older persons demonstrate a: -persistent, productive cough -wheezing -recurrent respiratory infections -shortness of breath Usually patients notice increased difficulty breathing in cold and damp weather Results in More frequent respiratory infections, or COPD exacerbation Episodes of hypoxia Bronchial tubes are constantly irritated and inflamed --> excessive mucus production (sticky, translucent grayish white sputum) --> have episodes of hypoxia D/T mucus obstruction of bronchial tree --> wheezing, chest pain, low fever, SOB Smoking is main cause of chronic bronchitis Management of chronic bronchitis is challenging -- depends on stage of disease First step is a change in lifestyle and means immediately quitting smoking, focusing on removing bronchial secretions and preventing obstruction of airway... similar for all age groups FOR OLDER ADULTS: -Ensure adequate hydration and expectoration of secretions -Teach importance of avoiding respiratory infections -Discouraging respiratory irritation (such as from smoking) As the disease progresses, emphysema may develop, and death may occur from obstruction Emphysema Walls between many of the air sacs are damaged, lose their shape and become floppy Damage over time can destroy walls of alveoli --> leading to fewer and larger alveoli instead of many tiny ones --> reduced gas exchange in lungs --> more effort required for breathing and hypoxia occurs, fatigue, anorexia, weight loss, and weakness over time Complications among older adults -Can experience recurrent respiratory infections -Malnutrition -CHF -Cardiac arrhythmias Management -Postural drainage -Bronchodilators -Avoid stress -Avoid extremely cold weather -Safe and regimented medication administration -Recognize symptoms of infection -Breathing exercises -Stop smoking!! Increasing incidence in older adults Symptoms slow in onset and can delay diagnosis and treatment Education and support Necessity of difficult lifestyle changes -Pace activities

Stasis Dermatitis

Common inflammatory skin disease in lower extremities Associated with chronic venous insufficiency Affects middle age and older adults, rare before 5th decade; risk of developing increases with age Usually the earliest sign of venous insufficiency; may be precursor to venous leg ulceration Reddish-brown skin discoloration early sign; may have prior of history of dependent leg edema -Medial ankle most frequently involved, progressing to foot and/or calf. Can lead to stasis ulcers formation. Stasis Ulcers -Often appear on medial ankle and prior to skin breakdown, present as a dark discoloration of the skin Treatment Need special attention to facilitate healing -Infection controlled -Necrotic tissue removed before healing will occur -Good nutrition is important -Diet high in vitamins and protein recommended -Elastic support stockings may be prescribed (may be difficult for older adults to apply) Prevention/avoid situations that promote stasis dermatitis -Diet for weight reduction or planning of high-quality meals -Venous return enhanced by ELEVATING LEGS SEVERAL TIMES A DAY -Avoid standing for long periods -Avoid sitting with legs crossed -Avoid wearing garters -Some require ligation (surgical tying of veins through a small incision in the skin to prevent pooling of blood) and stripping of veins to prevent further episodes (used to remove or tie off a large vein in the leg)

Summary of safe medication administration

Older adults are at increased risk for adverse reactions Effects of age-related changes -Less intracellular fluid -Increased gastric pH -Decreased gastric blood flow and motility -Reduced cardiac output and circulation -Slower metabolism ALL THESE CAN SLOW ABSORPTION. Reduced efficiency of liver and kidneys and the effect on drug excretion and metabolism

Intimacy

Encompasses more than just physical acts -Love, warmth, caring and sharing -Intimate exchange of words and touch -Feeling wanted by another person Multiple losses have a significant effect on intimacy -Comfort and satisfaction derived from a meaningful relationship are especially significant KEY CONCEPT: Sexuality includes love, warmth, caring, and sharing between people and identification with a sexual role

Measures to help RNs make ethical decisions

Encourage patients to express their desires/wishes -Advise patients to express desires in advance directives, wills, and other legally binding documents -Advocate compliance with patients wishes Identify significant others who impact and are impacted -Consider family members, friends, and caregivers who are involved with patient and the situation -Consider their concerns and preferences Know yourself and know the regulations/laws -Review his or her personal value system -Influences of religion, cultural beliefs, and personal experiences should be explored to understand one's unique comfort zone with specific ethical issues Read and discuss -Review medical literature for discussions and case experiences of other nurses to gain wider perspective into types of ethical problems -Strategies for managing them -Literature outside of the field of nursing can help add new facets to one's thinking -New perspectives Ethics committees Various members of health team, clergy, attorneys, and lay persons -Study ethical problems within specific care setting -Clarify legal and regulatory boundaries -Develop policies -Discuss ethical problems that surface -Investigate charges of ethical misconduct Consult an expert -Clinical ethics consultation takes form of an ethics committee or consultation provided by expert individuals or groups (lawyers, philosophers, clinicians who specialize in bioethics) -Provide education, mediate moral conflict, facilitate moral reflection, and advocate for patients Evaluate decisions -Assess the outcomes of the actions and whether the same courses of action would be chosen in a similar situation in the future Assisting Older Adults in Decision-Making: Assure patient is competent to make their own decisions (even if they don't have dementia) -If competency is in question, consult with organization's social worker or other designated professional to have surrogate properly appointed Document Assessment of factors influencing the ability to make decisions such as: -Mental status -Ability to express preferences -Mood -Effects of medications -Family influence Assessment findings: -Explanations given -Person's expressed preferences and concerns -other relevant info Offer explanations and information regarding treatment options -Increases understanding -Offer to include family members or s/o in discussion if person desires Assure the patient understands and has a clear picture of all the options -Understands the diagnosis, prognosis, treatment options, and risks and benefits of various treatments -Encourage person to ask questions and express concerns -If no question of confusion about procedures, request that the provider who will perform the procedure meet with the person to discuss the issue Assure patient not being coerced -Not feeling intimidated to state a refusal to give consent Ability to make competent decisions can fluctuate -due to medications, pain, etc. -Ensure that explanations are provided and decisions are made during times of lucidity DON'T LET PERSONAL VIEWS INFLUENCE PATIENTS DECISION!

The problems of falls (safety)

Incidence of falls in the older adult population -Each year 25% of persons aged 65 years and older experience a fall -1/5 of those falls resulting in serious injury -Falls are leading cause of fatal and nonfatal injuries in older population Consequences of falls -Even if no physical injury occurs; fall victims may develop fear of falling again (postfall syndrome) -Reduce activities -Unnecessary dependency -Loss of function -Decreased socialization -Poor quality of life Risks for falls Age related changes -Reduced visual capacity -Problems differentiating shades of same color (blues greens, and violets) -Cataracts -Poor vision at night and in dimly lit areas -less foot and toe lift during stepping -Altered center of gravity leading to balance being lost more easily -Slower responses -Urinary frequency Improper use of mobility aids -Using canes, walkers, and wheelchairs without being prescribed or properly fitted or instructed in safe use -Not using brakes during transfers Medications -Can cause dizziness, drowsiness, orthostatic hypotension, incontinence -Antihypertensives, sedatives, antipsychotics, and diuretics are risky Unsafe clothing/shoes -Poor fitting shoes and socks -Long robes or pants legs Disease-related symptoms -Postural hypotension -Incontinence -Reduced cerebral blood flow -Edema -Dizziness -Weakness -Fatigue -Brittle bones -Paralysis -Ataxia -Mood disturbances -Confusion Environmental hazards -Wet surfaces -Waxed floors -Objects on floor -Poor lighting -Clutter produced by hoarding Care-giver related factors (restraints, bedrails, delayed response) -Improper use of restraints and bedrails -Delays in responding to requests -Unsafe practices -Poor supervision of problem behaviors Prior history of fall increases risk of future falls Prevention of falls Postural hypotension Common problem that causes dizziness when older adults first stand after awakening -Spend several minutes resting in bed and stretching their muscles -Followed by several more minutes of sitting on side of bed and stretching muscles -Followed by several more minutes of sitting on side of bed before rising to standing position Orthostatic effects of rising to standing position after bathing, coupled with dilation of peripheral vessels from warm bath water --> leads to fainting and falls -Rubber mats or nonslip strips, a bath seat, and resting before rising are essential in bathtub Nursing assessment before a fall, assessment after a fall -Hendrich II Fall Risk Model Assessment after a fall -Keep him or her immobile until full examination for injury is done -Note Skin breaks or discoloration, swelling, bleeding, asymmetry of extremities, lengthening of a limb, and pain -Medical examination and x-rays are warranted for even slightest suspicion of fracture or other serious injury -Fractures are often not readily apparent immediately after fall; it may be only when person attempts to resume normal activity that injured bone becomes misaligned Programs to prevent falls -Regular, careful inspection of the environment and prompt correction of environmental hazards A program to prevent falls is essential to settings that provide serves to older adults

Interventions to reduce intrinsic risks to safety

Prevention of injury is essential Reducing risks related to hydration and nutrition -Thirst perception declines with age (less aware of fluid needs) -Maintain fluid (1500 mL daily unless contraindicated) and food intake -Other sources than water: soft drinks, coffee, tea, juices, jello, ices, and fresh citrus fruits Poor oral health, GI symptoms, altered cognition, depression, and dependency on others for feeding can lead to poor food intake -Fatigue, weakness, dizziness = poor nutritional status Addressing risks associated with sensory deficits Vision -Annual eye exams -Approach from front -Good lighting -Using contrasting colors on stairs -Providing signals to indicate when change in level is being approached -Eliminate clutter Bright reds, oranges, and yellows and contrasting colors on doors and windows can be appealing and helpful Hearing -Audiometric evaluation -Hearing aid from reputable vendor -Provide written directions -Alternative alert system (phone, fire, smoke) KEY CONCEPT: Conversation with hearing-impaired individual during the night can be facilitated by placing earpieces of a stethoscope into the impaired persons ears and speaking into the bell or diapgrahm Taste, smell, tactile -Observation, education, and environmental modifications as needed according to deficit -Electric stoves may be better option than gas stoves Addressing risks associated with mobility limitations -Slower response and reaction times as a safety hazard -Slower movement -Poor coordination (loose rugs, slippery floors, clutter, and poorly fitting slippers and shoes should be eliminated) -Poor judgement (denial or lack of awareness; advise not to take risks such as climbing ladders or sitting on ledges to wash windows) If family members not available to escort and transport individuals, assistance may be obtained through local social service agencies Monitoring body temperature -Avoid extremes of environmental temps -Be aware older persons body temp is lower; know baseline (temperatures as low as 97 degrees can be normal finding) -If slight elevation, can indicate infection (if it is 2 degrees above individuals norm) Unrecognized temperature elevation places added burden on heart -- for every degree elevation, heart rate increases ~10 beats/min (older hearts don't tolerate this well) Preventing infection -Avoid exposure or contact to persons who have known or suspected infection -Vaccines up to date (FLU yearly, Pneumococcal at age 65 years, tetanus every 10 years) -Maintain mobility, nutrition, hygiene Sensible clothing -Shoes that are too large, offer poor support, or have high heels can lead to falls -Loose hosiery and robes or pants legs that drag on floor = bad -Garters and tight-fitting shoes or garments = bad -Hats and scarves can decrease visual field Using medications cautiously -Prescribed -Aware of side effects Avoiding crime -Should be cautious when traveling alone or at night, opening doors to strangers, negotiating contracts, telephone and cyber crimes Promoting safe driving -Seat belt use -Drive when conditions are safe -No driving when impaired -Restrict driving to daylight hours and non-congested areas, good weather Early detection of problems Self-evaluation and recognize changes -Monitor body temp, pulse -May need to teach how to auscultate for lung sounds, if condition warrants -Observe for changes in sputum, urine, feces -Consider effectiveness of medications, side effects or adverse reactions -Recognize when necessary to contact PCP New onset of confusion, disorientation, poor judgement, decreased memory are NOT normal findings!!! -Often root of the problem can be a reversible disorder such as hypotension, hypoglycemia, or infection

COPD Rationale

There are health benefits to quitting smoking at any stage and doing so would likely aid in the treatment of the client's COPD Continuing to smoke, while detrimental, would not necessarily render all medical treatments for COPD Quitting smoking could stop the progression of the client's disease

Pressure injury (pressure ulcer)

Tissue anoxia and ischemia result in necrosis, sloughing, and tissue ulceration (pressure ulcer) Staging Deep tissue injury = a purple or maroon area of intact skin or blood-filled blister due to damage of underlying tissue. -Nonblanchable -Area can be painful, firm or mushy, warm or cool. -Can progress quickly and expose additional layers of tissue Stage 1 Persistent area of skin redness (WITHOUT BREAK IN SKIN) -Does not disappear when pressure is relieved -Usually over bony prominence Stage 2 Partial-thickness loss of skin layers involving the epidermis that presents clinically as an intact or open/ruptured blister, or open shallow crater Stage 3 A full thickness of skin is lost extending through epidermis -Exposes subcutaneous tissues -Presents as deep crater with or without tunneling and undermining adjacent tissue Stage 4 A full thickness of skin and subcutaneous tissue is lost -Exposes muscle, bone, or both -Presents as deep crater that may include necrotic tissue, slough, or eschar -Tunneling and undermining often is present Unstageable full thickness loss of tissue with the base covered by slough and/or eschar Stage cannot be determined until slough or eschar is removed to expose the base and actual depth of wound Common sites Over bony prominences -Sacrum -Greater trochanter -Ischial tuberosities Factors that place older adults at high risk -Have skin that is fragile and damages easily -Are often in a poor nutritional state -Have reduced sensation of pressure and pain -Are more frequently affected by immobile and edematous conditions (which contribute to skin breakdown) Longer healing periods -SO NEED TO PREVENT! Prevention Priority intervention -Continued assessment for "at risk"; PREVENTION IS KEY! -Avoid unrelieved pressure -Encourage activity -Turning patient who cannot move independently -Turning schedule of 2 hours is not ALWAYS sufficient -Shearing forces prevented by not elevated head of bed more than 30 degrees -Not allow patients to slide in bed -lifting instead of pulling Nursing interventions -Special mattress -Skin protective ointments -Position changes -Protective dressings -Nutritious diet -Bedding wrinkle-free and no foreign objects in bed -Avoid unrelieved pressure -LIFT; don't drag skin across bed sheets -Maintain body alignment -Use pillows -Lamb's wool & heel protectors (prevent irritation to bony prominences) -Sensitivity needed when medical devices are being used (braces, BP cuffs) -High-protein, vitamin rich diet to maintain and improve tissue health -Good skin care (skin kept clean and dry) -Blotting patient dry will avoid irritation from rubbing with towel -Bath oils and lotions help keep skin soft and intact -Massages of bony prominences and ROM exercises promote circulation Characteristics Treatment measures depend on the state of pressure injury as identified by following signs: Hyperemia Redness of the skin appears quickly and can disappear quickly if pressure is removed -No break in skin and underlying tissues remain soft -Relieving pressure by use of a square of adhesive foam is useful -Protect skin with product such as DuoDerm or Tegasorb before applying adhesive Ischemia Redness of skin develops from up to 6 hours of unrelieved pressure and is often accompanied by edema and induration -Can take several days for this area to return to normal color, during which epidermis may blister -Skin protected with Vigilon (contains water and is soothing to area) -If skin surface is broken, clean daily with normal saline or product suggested Necrosis Unremitting pressure extending over 6 hours can cause ulceration with necrotic base -Requires transparent dressing that protects from bacteria but is permeable to oxygen and water vapor -Thorough irrigation is essential during dressing changes -Sometimes topical antibiotics used -May take weeks to months for full healing to occur Ulceration -If pressure not relieved, necrosis will extend through fascia and potentially to bone -Eschar is present and bone destruction and infection may occur -Unless eschar is removed, underlying tissue will continue to break down so debridement is essential KEY CONCEPT: Reverse staging of a pressure injury should not be done. As the injury heals, refer to it as "healing stage ____" and state the highest stage at which the injury was assessed to be.

CV Disease & Women

With age, prevalence increases Symptoms often missed or ignored, because symptoms are less evident than in men -- this fact delays treatment MI Symptoms LESS OBVIOUS -Burning sensation in upper abdomen or upset stomach -Lightheadedness -Sweating -May not feel typical chest pain in L chest or radiation of pain Signs of a heart attack Head: Lightheadedness Arms, Back, jaw, neck between shoulders: -Pain -Discomfort -Numbness Chest: -Pain, pressure, fullness, or squeezing (lasts more than a few minutes or comes and goes) Skin: -Cold sweat Lungs: -Trouble breathing (shortness of breath) Stomach: -Upset stomach -Urge to throw up Other signs: -May feel very tired, sometimes for days or weeks before a heart attack occurs -May also have heartburn -A cough -Heart flutters -Lose their appetite Risks -High BP -High blood cholesterol -DM -Obesity -Smoking -Physical inactivity -Family history of heart disease Modifiable risk factors for women -Smoking cessation -If hypertension, treat and monitor -Diet -Exercise -Improve LDL and HDL cholesterol levels -Weight loss (obesity is strong predictor for heart disease) -control diabetes -alcohol intake in moderation -reduce stress Educate -Know risk factors -Reach and keep healthy weight -Reduce saturated fat and salt from diet -Move more -Quit smoking -Reduce stress