Gero - Exam 2

Mini-cog

*Also used to assess for dementia* -Equivalent to MMSE -*Combination of MMSE and CDT* -Short-term memory and executive function -*Must hear, hold pencil, write numbers* Directions: Give pt paper to do CDT and begin with *asking them to remember 3 unrelated words* (ball, sky, shoe). Wouldn't say something like shirt, pants, tie because those things are related & can be remembered more easily. Then immediately go into CDT where you have them draw a time. After they've drawn the clock, say "tell me those 3 words again" Scoring: -points awarded for recalled words first; *all 3 remembered = dementia unlikely.* -*None remembered = dementia likely.* -normal: all numbers/hands correct -abnormal: any errors

Home safety evaluation - problems & interventions for bathroom

*Bathroom is the MOST dangerous place in house for older adult* 1. getting on & off toilet: raised seat, side bars, grab bars 2. getting in & out of tub: bath bench, hand-held shower nozzle, rubber mat 3. hot water burns: check water temps before bath, set hot water thermostat to *120 F or less* 4. doorway too narrow: remove door; leave wheelchair at door & use walker

Home safety evaluation - problems & interventions for kitchen

*Kitchen is also extremely dangerous for older adults* 1. open flames & burners: *avoid using.* substitute microwave, electric toaster oven 2. access items: place commonly used items in easy to reach areas, adjustable height counters/cupboards 3. difficulty seeing: adequate lighting, utensils with brightly colored handles

Laxatives (4)

*Listed in order of how we should try to administer them* 1. Bulk-forming (fiber)- psyllium (Metamucil) -*First line and contraindicated in very frail elders or those with dysphagia*; need to drink metamucil really fast or it gets thick like a gelatin, therefore those with trouble swallowing should not take. 2. Emollients - docusate sodium (stool softener) -*pulls moisture into stool* to help prevent constipation 3. Osmotic- milk of mag, lactulose -more powerful & *causes a greater shift of water into the stool* -lactulose is used in pts with liver failure to decrease levels of ammonia, but can be used as a laxative in those who don't have liver problems -*Often causes diarrhea so need to assess electrolyte levels* 4. Stimulant - bisacodyl -Stimulates peristalsis -*would like to avoid in older people; have an increased risk of causing a bowel perf with the increase in peristalsis & squeezing* -Often causes cramping -May cause dehydration and electrolyte disturbances

Clock drawing test (CDT)

*Screens AND diagnoses dementia* -not for mild cognitive impairment -*Manual dexterity and visual acuity required* (not appropriate for blind, Parkinson's disease, stroke, severe arthritis - *can result in a false positive*) Directions: -provide white plain paper with circle drawn on it, 5 in diameter -ask person to draw numbers in the circle so that it looks like a clock and then put hands to read "10 after 11" Scoring: -*score of 1 or 2 is considered normal* -*score of > 3 represents a cognitive deficit.*

Limited access to safe transportation contributes to: (3)

1. *Social isolation, decreased self worth, & depression* -not socializing with others can have a huge impact on mental health 2. Poor nutrition 3. Neglect of health -*inability to go to grocery store as often as needed results in buying foods that will last & aren't necessarily healthy* -*Transportation is critical for the older adult to remain independent & functional* -Area agencies can provide information and resources to help older adults with limited transportation accessibility

Fluid quality to maintain hydration

1. *Water is best: bulk of fluid intake should come from water* 2. Second: milk, fruit juice, & non-salty soups are ok; not as good as water but still hydrating. 3. Coffee and tea: not so great, have diuretic effects but can still be hydrating. Definitely should not be bulk of person's fluid intake. 4. Alcohol should NEVER be recommended for hydration purposes; it's dehydrating & has a diuretic effect

Factors affecting fulfillment of nutritional needs

1. Age associate changes in taste and smell 2. Oral health status 3. Chronic diseases and conditions 4. Side effects of medications 5. Lifelong eating habits 6. Socialization 7. Anorexia of aging 8. Income 9. Transportation 10. Housing *40% - 60% of hospitalized older adults are malnourished or at risk for malnutrition* in the United States due to: -Severely restricted diets -Prolonged NPO status -Insufficient time for feeding assistance

Dehydration 4 categories

1. Can drink -able to drink, don't have any problems drinking fluids -just don't know how much they should be drinking/what's adequate -Possible cognitive impairment causing them not to remember to drink -Need to encourage & make fluids accessible 2. Can't drink -Physically incapable of ingesting or accessing fluids; may have dysphagia or had a stroke -Need to focus on dysphagia prevention -*Assess swallowing & do a swallow evaluation*; collab with a speech/language pathologist -Teach safe drinking techniques/ interventions for dysphagia -Person who can't drink may also have a peg tube & are reliant on nurses to get them fluid. When reliant on someone, there's a big risk you won't get enough. This may be a situation where you would get an order for water 3. Won't drink -*Highest risk for dehydration* -Able to drink but refuses/limits intake for some reason -*may be due to fear of incontinence or cognitive impairment* -for fear of incontinence, providing teaching (scheduled voiding, kegel exercises) 4. End of life -Terminally ill -could be any of the previous 3 (can, can't, or won't drink) -*Must refer to advanced directives with regard to hydration wishes* -if person is actively dying or we expect them to die very soon, urinary output is not a priority; there are no life saving measures. Keep in mind that the goal may not be to rehydrate the person.

3 Temperature vulnerability factors

1. Caretakers/family -Monitor individual who has cognitive or physical limitations that affect ability to respond to changes in temperature 2. Economics -When an older person *cannot afford proper heating or air conditioning* -*major cause of temp vulnerability* 3. Safety concerns might prompt older adults to bolt doors and windows, creating unsafe temperature in home environment -unable to open up windows to let a breeze in, creating higher temps; also unsafe if unable to open window if there's a fire in the house

Hyperthermia prevention (8)

1. Drink 2 to 3 L of cool fluid daily (as tolerated) -important in prevention, as well as in treatment. Person most likely will have sweated out circulating fluid volume. 2. Minimize exertion, especially during heat of day 3. Stay in air-conditioned places, or use fans 4. Wear hats and loose clothing of natural fibers when outside; remove most clothing when indoors 5. Take tepid baths or showers 6. Apply cold, wet compresses, or immerse hands and feet in cool water 7. *Evaluate medications for risk of hyperthermia* 8. Avoid alcohol

Fire safety - 3 risk factors

1. Economic or climatic conditions may promote use of *ill-kept heating devices* 2. Attempts to *cook over open flame while wearing loose-fitting clothing* 3. *Inability to manage spattering grease from frying pan can often start fire* from which elder cannot escape

2 General assessment tools

1. FANCAPES *F*luids *A*eration (oxygenation) *N*utrition *C*ommunication *A*ctivity *P*ain *E*limination *S*ocial skills 2. SPICES *S*leep disorders *P*roblems with eating/feeding *I*ncontinence *C*onfusion *E*vidence of falls *S*kin breakdown -*Not scored; yes or no answers.* *Purpose is to gather a baseline assessment & go further with it* using more specific assessment tools according to pt's answers

Interventions to improve nutritional status

1. Family involvement when possible 2. Use of nutritionally dense supplements with medication pass 3. Restorative dining rooms 4. Consideration of ethnic food choices 5. Easy access to refreshment stations with juices, water, and healthy snacks 6. Liberal diets 7. *Finger foods* -*good for those with alzheimer's who can't sit still. They're able to walk around & eat* 8. Visually appealing pureed foods 9. Establish routine for meals and snacks consistent with accustomed eating schedule 10. Incorporate favorite foods, especially nutritionally dense foods and finger foods 11. Visual cueing and hand-over-hand assistance as needed 12. Appropriate utensils and dinnerware 13. Offer fluids in between bites of food 14. Eliminate distractions 15. Allow time for older person to enjoy and complete meal

Fecal impaction nursing management

1. First prevent - *prevention of constipation is the most important thing for nurses to do.* 2. Removal of impaction -Digital removal of hard stool from rectum -Use copious lubricant -May take several days -Don't dis-impact too much -Often very painful If person has large impaction, evacuation of stool may actually cause problems & the person can vagal down (vagus nerve becomes stimulated & person becomes bradycardic & hypotensive)

Hyperthermia 3 stages

1. Heat fatigue -pale, sweaty, elevated HR -*normal temp* -typically when an older person has heat fatigue it's *missed & overlooked* as just being hot, *but it can quickly lead to heat exhaustion* 2. Heat exhaustion -cramping, *cool/clammy,* tachycardia, thirsty, *altered mental status*, nausea -*temp normal or mild elevation* 3. Heat stroke = MEDICAL EMERGENCY with high mortality in older adults -*defined as temp higher than 104* -start to have *cellular & organ damage*; body is not compatible with a temp of 104 -flushed, *HOT & DRY*, tachycardia, *mental status change*, hypotension, hyperventilation (mechanism to lower body temp)

Fall, balance, & gait assessment

1. Hendrich II -*includes the get up & go test*: person's ability to independently rise from a chair with not a lot of effort, stand up, walk, & then come back to the chair. -assesses how many attempts it takes; are they successful, does it take them a couple of times of rocking to get out of the chair, or are they unable to rise without assistance -*objectively assesses the older adults risk for falling* -males get a point just for being a male. *Older men are more likely to fall than women* 2. Tinetti Balance & Gait -*test includes nudging patient to assess their balance*; if pt does have an issue with balance, they will most likely fall over so this *should be done as a team* -assessment typically done by physical therapy -*if score is low, pt has a high risk for falls*

Culturally sensitive assessment (7)

1. How would you describe the problem that has brought you here? 2. How long have you had this problem? 3. What do you think is wrong with you? 4. Why do you think this happened to you? 5. What are the chief problems your sickness has caused you? 6. What do you think will help this problem? 7. Apart from me, who else do you think can make you feel better?

4 complications of constipation

1. Impaction which can lead to an obstruction --> bowel perf --> sepsis 2. Increase in falls 3. Delirium, change in mental status 4. The more constipation a person has over their lifetime, *the higher the risk for bowel cancer*

7 Risk factors for hypothermia

1. Impaired circulation 2. Diabetes 3. Adrenal or thyroid dysfunction 4. Malnutrition 5. Excessive alcohol use 6. Inadequate housing or supervision 7. Use of sedatives, anxiolytics, antidepressants

Constipation nursing management (3)

1. Increase physical activity -*important intervention to stimulate colon motility & bowel evacuation through movement of the body* -walking 20 or 30 min is helpful, especially after a meal -pelvic tilt exercises & ROM exercises are beneficial for those who are less mobile 2. Positioning -*squatting or sitting position facilitates bowel function. Similar position may be obtained by leaning forward* & applying firm pressure to lower abdomen or by *placing the feet on a stool* -rocking back and forth may facilitate BM 3. Toileting regimen -*establishing a routine for toileting*, like going at the same time everyday, *promotes or nomalizes bowel function* -bc there is a lot of variation between individuals & their BM routine, it's important to know baseline to be able to determine if there's any changes -gastrocolic reflex *occurs after breakfast or dinner; good time to attempt a BM is about 30 min after these meals.* -allow at least 10 min for a BM 4. Increase fluid intake - at least 1.5 L per day (2-3 L is best; older adults *need just as much water as younger adults*) 5. Increase dietary fiber -*dried fruits, dried beans, vegetables, & wheat products* 6. Laxatives 7. *Enemas = LAST RESORT* -should NOT be used on a regular basis bc a person can become dependent on it & can actually cause constipation -bc enemas cause diarrhea, it may alter fluid & electrolyte status -*sodium phosphate enemas are contraindicated; should be tap water only*

How to identify if client is having difficulty swallowing

1. Labored swallowing (takes effort to swallow) 2. Coughing or choking 3. Increased oral secretions 4. Pocketing food in mouth -can mean 2 things: they're putting food in cheeks or literally putting food in their pockets to make you think that they're eating 5. Increased eating time 6. Throat clearing 7. Pain 8. Hiccups 9. Chest pain 10. Gurgly voice -not normal & indicates a problem. Need to teach pt not to talk with mouth full 11. Frequent respiratory infections 12. Spitting *Nurse will most likely be the first to detect that a person is having difficulty swallowing*

Effective assessment of older adult requires the nurse to: (6)

1. Listen patiently 2. Allow for pauses -*can take older adults longer to respond & to process questions, especially if they have any cognitive decline or mental impairment* -in clinical practice, when an older adult doesn't respond to a question we immediately ask them in different words & say it louder BUT we just need to give them extra time -*DO NOT assume that an older person can't hear you. Talk in a normal tone & if they say "what" then you speak up* (this can be done as a baseline assessment) 3. Ask questions -closed ended questions are necessary when performing an assessment. For example, "do you have HTN" 4. Observe minute details 5. Obtain data from all sources 6. Recognize normal changes associated with late life

Sleep hygiene (10)

1. Maximize comfort 2. *Bedroom is for two things only - sleep & sex* -shouldn't be watching tv or eating in bedroom bc then brain thinks the room is for more than sleeping 3. Avoid or limit naps -*don't want them taking more than 1 nap per day & it should be 30 min or less* 4. Exercise and outdoor time -should NOT be exercising right before bed. -*exercise during the day can increase sleep* 5. Bedtime routine -at the same time everyday, teach them to begin getting ready for bed & do the same thing every night; gets body in mode for sleep 6. Avoid stimulants and ETOH, esp late in day 7. Manage GERD -GERD can wake person up. Person lays down & has water brash (episode of reflux coming up back of throat & can even cause aspiration) 8. Avoid screen time just before bed 9. If can't fall asleep, get up and go to another room until feeling sleepy 10. Older adults should avoid sleep aids in general -if needed, Melatonin or zolpidem (Ambien) is best; however, *ambien can cause profound sleepiness* & the person may sleep for a very long time, esp when they first start taking it -*sleep walking is also common when taking ambien (older adults are at risk for falls)* -*melatonin is safer/has less side effects*

Cognition & mood assessment tools

1. Mini-Mental State Examination (MMSE) -screen for & monitor cognitive function -*30 item test used to rule out dementia; NOT a diagnosis* -*if results are negative, can say pt doesn't have dementia* -tests orientation, short-term memory and attention, calculation ability, language & construction -*must be able to read, write, & be english proficient* 2. MMSE-2 -*less specific & quicker* -ask questions like what day is today, what is this (pointing to eye)

Interventions to maintain hydration

1. Need at least 1.5-2 L per day -person may not know how much this is, so *teach them 8 8oz cups of fluid per day* 2. Offer fluids often 3. Make fluids readily available 4. Encourage fluids with meds 5. Provide preferred fluids -if they won't drink water but they'll drink tea, give them tea 6. Verbal reminders

Thermoregulation (3)

1. Neurosensory changes: *diminished or delayed perception of temp changes*; may not feel it's getting hot or cold 2. Physiological changes: *impaired cooling & warming responses to temp changes* (shivering & sweating) 3. Medications & alcohol: impair vasomotor response, inhibit neuromuscular activity, suppress metabolic heat generation, and/or dull awareness of surroundings -older adults are *more sensitive to meds & alcohol that may cause alteration in temp.* -for example, *risk of malignant hyperthermia with antipsychotics is increased*

Temperature monitoring

1. Older adults have a diminished thermoregulatory response - *impairs ability to respond to infection with fever* 2. Frail older adults have *lower baseline temperatures than younger adults* 3. Absence of fever *does not rule out infection; a one degree change from baseline may be significant in older adults* 4. High fevers (≥ 38.3 ̊ C; 100 F) are serious and *associated with bacterial and viral infection*

Health history 4 components

1. Past medical history 2. Review of symptoms 3. Medication history -Prescribed, OTC, "Home remedies", & herbals/dietary supplements -*must ask specifically about meds* 4. Social history - living arrangements, resources, & support systems -*asking are you able to take care of yourself, does someone else help take care of you, who is your social support, do you have family* -when asking an older adult if they can take good care of themselves *they will most likely say yes. They don't want their independence taken away*

Health assessment of older adults includes: (6)

1. Physical data 2. Biological 3. Cultural - religion, beliefs, practices 4. Psychosocial - family relationships, social activities 5. Functional aspects - physiological & anatomical 6. Growth & development Should be doing comprehensive assessments on all clients, especially older adults. Looking at pt in a holistic fashion - complete health history & assessment

Thermoregulation - health promotion (4)

1. Recognition of clinical signs of hyperthermia and hypothermia 2. *Monitoring of body temperatures against baseline* in older adults 3. Establish surveillance system for community dwelling older adult clients 4. Social service referrals for assistance with heating and electrical bills

Urinary incontinence 6 interventions

1. Scheduled & Prompted voiding -scheduled voiding: tell person to go every 2-3 hrs whether they feel like or not -prompted voiding: remind person to go 2. Pelvic floor muscle exercises (kegels) -increases tone of the muscles that hold urine in the bladder 3. Thorough assessment of continence -how long has it been going on, when did it start, is it happening during the day or at night -*asking these questions helps to identify whether it is new onset & could be a UTI* 4. Lifestyle Modifications -Avoid caffeine (not much evidence), smoking cessation, bowel mgmt, healthy weight, exercise 5. Medications -*Most have anticholinergic effects & cause urinary retention* -also have meds that can decrease the spasms of the bladder 6. *Urinary catheters = last resort*

Important components of health assessment for older adults

1. Self-report of functional status 2. Home assessment -*#1 thing we're concerned about with older adults is safety in their homes* 3. Psychological aspects -Cognitive -Emotional: *older adults have higher rates of depression & social isolation, so need to ask specifically about these things* -medicare says that *every time an older adult visits their HCP they MUST be screened for depression* 4. Roles - caregiver, family structure -ask, "do you care for someone else?" *often, older adults do care for someone else. It could be their spouse, sibling, or even an older parent.* 5. Decision-makers in family

6 difficult & sensitive subjects to assess

1. Sexual dysfunction 2. Depression 3. Incontinence 4. Alcoholism 5. Hearing loss -*people are reluctant to reveal that they have hearing loss bc again they feel their independence will be taken away* 6. Memory loss or confusion When assessing these difficult & sensitive subjects, *ask open ended questions at first & then more specific, closed-ended questions as you go* -also *assess person's willingness to talk* about these issues

Feet age-related changes (5)

1. Skin becomes drier, less elastic, cooler bc they are less well-perfused 2. Subcutaneous tissue on dorsum (top of foot) and sides of foot thins 3. Plantar fat pad (bottom of foot) shrinks and degenerates 4. Toenails become brittle, thicken, *less resistant to fungal infections* 5. Degenerative joint disease decreases ROM

Proper foot care

1. Teach pt importance of yearly foot exam by HCP - especially if the patient has diabetes 2. Care of toenails -*best cut after soaking for 20-30 min* -clip straight across, not at a curve. *Clipping at a curve can cause infections & ingrown toenails* 3. Wear proper fitting footwear 4. Wear orthotic shoes as needed

Exercise safety

1. Wear comfy loose fitting clothing that absorbs sweat & appropriate shoes 2. warm up for 5-10 min 3. drink water before, during, after 4. never wear rubber or plastic suits 5. Stop exercising if you: have CP, break out in a cold sweat, feel dizzy/sick, have muscle cramps, feel acute pain in joints, have trouble breathing (need to slow down) 6. Times exercising shouldn't be done: 2 hrs after a big meal, when you have a fever/infection accompanied by muscle aches, if BP is 200/100, if joint is red/warm/painful, if you experience pain/swelling in joint, if you have a symptom not yet evaluated by HCP, avoid stretches that flex spine if you have OP

Home safety evaluation - problems & interventions for steps

1. cannot handle: stair glide, lift, ramp 2. no hand rails: install at least on one side 3. loose rugs: remove or nail down to wooden steps 4. difficult to see: adequate lighting, mark edge of steps with bright colored tape 5. unable to use walker on stairs: keep 2nd walker or wheelchair at top or bottom of stairs

Home safety evaluation - problems & interventions for safety

1. difficulty locking doors: remote controlled door lock, door wedge, hook and chain locks 2. difficulty opening door and knowing who is there: automatic door openers, level doorknob handles, intercom at door 3. opening & closing windows: lever and crank handles 4. can't hear alarms: blinking lights, vibrating surfaces

Preventing fires & burns (9)

1. do not smoke in bed or when sleepy 2. when cooking, do not wear loose fitting clothing 3. set thermostats for water heater or faucets so that the water does not become too hot 4. install a portable hand fire extinguisher in the kitchen 5. keep access to outside door unobstructed 6. identify emergency exits in public buildings 7. if considering entering a boarding or foster home, check to see that it has smoke detectors, a sprinkler system, & fire extinguishers 8. wear clothing that is nonflammable or treated with a permanent fire-retardant finish 9. use several electrical outlets rather than overloading one outlet

Home safety evaluation - problems & interventions for home management

1. laundry: easy to access, sit on stool, good lighting, fold laundry sitting at table, carry laundry in bag on stairs, use cart, use laundry service 2. mail: easy to access mailbox, mail basket on door

Physical activity & exercise participation

1. provide appropriate screening before beginning an exercise program 2. assess functional abilities & how exercise can enhance them 3. provide info about benefits of exercise 4. clarify misconceptions (fatigue, injury) 5. assess barriers & how to overcome 6. provide an "exercise prescription" 7. set short term & long term goals 8. encourage use of journal to reflect 9. provide choices 10. provide self-monitoring methods to visualize progress 11. try to make it fun & entertaining; group or buddy may make it more successful 12. discuss side effects & what should be reported 13. provide safety tips 14. begin with low intensity for sedentary individuals 15. low intensity activities in short sessions & include warm up & cool down with active stretching (teach importance of this); progression from low to moderate intensity is important for max benefits 16. encourage use of proper well-fitted footwear 17. lifestyle activities can build endurance when performed for at least 10 min

10 health benefits of physical activity

1. reduced risk of HTN, CAD, MI, stroke, diabetes, colon & breast cancers, metabolic syndrome, depression 2. reduced adverse blood lipid profile 3. prevention of weight gain 4. improved cardiorespiratory & muscular fitness 5. reduced risk of falls & hip fracture 6. improved sleep quality 7. improved bone & functional health 8. decreased risk of early death 9. improved functional independence 10. improvement in walking speed, strength, functional ability

Home safety evaluation - problems & interventions for bedroom

1. rolling bed: remove wheels, block against wall 2. bed too low: leg extensions, block, 2nd mattress 3. lighting: bedside light, night light, flashlight on walker or cane 4. remove sliding rugs, tack down, rubber back, two-sided tape 5. slippery floor: nonskid wax, no wax, rubber sole footwear, indoor-outdoor carpet 6. thick rug edge/doorsill: metal strip at edge, remove doorsill, tape down edge 7. nighttime calls: bedside phone, cordless phone, cell phone -phone difficult to hear: headset, speaker phone -phone difficult to dial: preset numbers, large buttons, voice activated

Home safety evaluation - problems & interventions for living room

1. soft, low chair: board under cushion, pillow/blanket to raise seat, blocks or platforms under legs, good armrests to push up on 2. swivel & rocking chairs: block motion 3. obstructing furniture: relocate or move to clear paths 4. extension cords: run along walls, eliminate unnecessary cords, place under sturdy furniture, use power strips with breakers

3 types of urinary incontinence

1. urge -*overactive bladder* -defined as *8 or more episodes of incontinence per day, nocturia, & urgency* 2. stress -from *increased intraabdominal pressure* (sneezing, coughing, laughing) -defined as *leakage of 50mL or more* 3. functional -nothing wrong with urinary tract (urge & stress there is a physiologic reason) -*just can't get to restroom for some reason*

Reducing fire risks in the home (9)

1. when you smell smoke, see flames, or hear the sound of fire, evacuate everyone before doing anything else 2. use normal exits unless blocked 3. make sure smoke alarms are installed on each level of home & outside all sleeping areas; test alarms monthly & replace batteries at least once a year 4. know at least 2 exits from every room 5. make necessary accommodations, such as providing exit ramps & widening doorways to facilitate an emergency exit 6. contact local fire dept nonemergency number and explain special needs 7. in high-risk apt, remain in the room with doors & hall vents closed unless smoke is in apt. open or break window to obtain fresh air 8. rehearse what to do if clothing catches on fire: do not run. If another persons clothing is burning, smothers the flames with the hardiest item 9. if you live in a multistory home, arrange to sleep on the ground floor near an exit

_____ of adults 65 and older are obese

1/3. -Recently seen sharp rise in obese or overweight older adults Obesity paradox: some research has found that *being overweight might be protective in those who are 70 or older* -Does not mean to tell older adults to gain weight, but we notice that people who are 70 or older and mildly obese tend to live longer. -If the person is below the age of 70 & obese, they do not live longer Healthy weight throughout life is intervention best supported by evidence. So if a person has been a normal weight throughout their whole life & gains a few pounds at 75 we're not worried about it.

______% of older people experience constipation & is more common in _______

40%; more common in women Constipation is a reduction in bowel movement frequency or difficulty in forming or passing of stool

Nearly ___% of hypothermia deaths occur in older adults

50% 1. *Defined as core temperature < 35 º C (95 º F)* 2. Mild, moderate, or severe depending on core temperature 3. Can occur with *exposure to extreme cold environmental conditions* or *exposure in room temperature without protection* 4. *First Sign = mental status change*; may be confused & disoriented 5. *GOAL: Temp >97º F* -if person's normal temp is in 96's that's okay as long as it's within their baseline. -should begin intervening before they get to 95

More than ___% of older adults over the age of 50 don't get enough exercise, while ____% over 75 don't get enough.

60% over 50; 90% over 75

Restraints & side rails

A restraint is any device that limits the movement of a person *Try not to use restraints in older adults EVER if possible.* Consequences of restraints in older adults: 1. *DOES NOT effectively prevent falls, wandering, or removing medical equipment* (IVs, monitors) 2. Restraints *can actually exacerbate the problem & make it worse* 3. Restraint-related death: a *big problem with restraints is a risk for asphyxiation* (cutting off the airway) & can lead to death. 4. Restraints *increase the risk of pressure ulcers, agitation, cognitive decline, & depression.* 5. Side rails are not simply a part of the bed - they're a type of restraint if 2 full length rails are up or 4 half length rails are up -*requires a HCP order* 6. Research evidence does not show side rails reduce falls or injury -some evidence that they may increase injury -the more side rails that are up, the more dangerous the bed is. Can lead to falls if person is trying to get up & climbs over rails 7. CMS requires documentation of need for side rails

The nurse performs a Katz assessment of Independence in Activities of Daily Living (IADL) on an 81 year old male client. The nurse evaluates that the client exhibits independence if he does which of the following? (Select all that apply) A. Bathes self each day B. Needs help wiping after toileting C. Makes it to restroom without incontinence D. Needs help while eating E. Dresses self each day

A. Bathes self each day C. Makes it to restroom without incontinence E. Dresses self each day

The nurse responds to an older client who is suspected of experiencing heat fatigue at an outdoor event. What is the priority nursing intervention? A. Transfer the client inside a cool building B. Place the client in a dorsal recumbent position C. Assess the client's last incidence of urination D. Assess client's skin on the chest for tenting

A. Transfer the client inside a cool building

Precancerous skin lesion. Use sunscreen

Actinic keratosis (due to sun exposure)

Risk factors for changes in fluid balance

Adequate fluid consumption & maintenance of fluid balance is essential to health 1. Physiological changes in body water content -older adults *seem to dehydrate more easily than younger adults bc they have a lower baseline level of body fluid & water in their body. They also have less muscle content which holds fluid better than fat content.* 2. Impaired thirst sensation 3. Medications 4. Functional impairments 5. Chronic illness 6. Emotional illness 7. High environmental temperatures

_________ & __________ are risk factors for both hypo & hyperthermia

Alcohol use & inadequate housing

Malnutrition

Another type of geriatric syndrome 1. Rising incidence of malnutrition in acute care, long-term care, & in the community 2. *Institutionalized older adults are at high risk for malnutrition due to chronic disease and functional impairments* -when a person requires another person to physically feed them in order to get nutrition, they are at very high risk for malnutrition 3. Malnutrition increases risk of infection, pressure ulcers, anemia, hip fractures, hypotension, impaired cognition and increased morbidity and mortality 4. Comprehensive screening and assessment is critical to identify older adults at risk

Dehydration nursing management

Assess signs of dehydration: 1. Skin turgor (unreliable) 2. Weight 3. Mucous membranes 4. Speech changes 5. Tachycardia 6. Decreased urinary output 7. Dark urine 8. Weakness 9. Dry axilla 10. Sunken eyes *Many of these signs are unreliable in older people* (decrease in skin turgor as a physiologic change associated with aging, changes in sweating, etc) -Assessment of hydration needs to be holistic; must look at overall picture -If dehydration is suspected in an older adult, *can't diagnose based on a physical exam; labs must be drawn to see what electrolyte balances are - generally always confirmed with lab testing*

Functional assessment - IADLs

Assesses person's ability to perform tasks for *independent living* -Needed to *maintain one's home* -*Tool: Lawton*

Functional assessment - ADLs

Assesses person's ability to perform tasks of *self-care* -Needed to *maintain one's health* -*Tool: Katz*

Fall risk assessment

Assessment tools: 1. Hendrich II Fall Risk Model 2. Morse Fall Scale 3. Minimum Data Set (MDS 3.0) Major risk factors: 1. Orthostatic hypotension 2. Cognitive impairment 3. Impaired vision and hearing 4. Medications 5. Environmental factors 6. Weakness and frailty

Bony deformities on feet. May have custom shoes made, surgery, or steroid injection to treat.

Bunions

An older client who is at risk for falling has multiple throw rugs in the home. The nurse performs which action to best eliminate the risk of falling? A. Tack down the rugs to the floor B. Apply rubber backing to the rugs C. Remove the rugs from the home D. Apply two-sided tape to the rugs

C. Remove the rugs from the home

Yeast infection often in skin folds. Keep skin clean and dry. Keep DM in check.

Candidiasis

Thick, compacted skin. OTC preparations to remove, padding, avoid sharp tools.

Corns/calluses -Corn is a type of callus; gets a hard center piece in it & as the corn is pressed it causes lots of pain

The nurse performed a geriatric depression scale assessment on a 76 year old client and suspects a positive screen for depression and suicidality. What is the priority nursing intervention? A. Notify the healthcare provider immediately B. Document the assessment findings C. Repeat the screening on a separate day D. Ask client about current self-harming thoughts

D. Ask client about current self-harming thoughts

__________ is a reduction in total body water

Dehydration -A geriatric syndrome Dehydration in older adults is *often due to a disease process*: DM, HF, respiratory disease, frailty -treatment for HF is fluid restriction so person may only be allowed 1 L per day Complications: 1. Delirium -can occur very easily bc of dehydration 2. Thromboembolism (clot) 3. Infection 4. Renal failure 5. Kidney stones 6. Constipation 65-74 yo: 63% don't get enough fluid 75-84 yo: 73% 85+ yo: 81%

Minimum data set 3.0 (MDS)

Developed by medicare & medicaid services; *comprehensive assessment of long term care facilities used to plan, monitor, and describe the care delivered to residents* -Evidenced-based measures for pain, cognition, delirium, depression, ADLs; *includes resident interviews* -are facilities assessing for residents' changes in cognition, their pain, etc. *Multi-disciplinary tool that focuses on PT, social work, & nursing care*

Adequate ______ is an important factor in delaying onset & managing chronic illness associated with aging

Diet -Adequate nutrition is a *key factor in maintaining the health of older adults* -Proper nutrition includes all the essential nutrients: carbs, fat, protein, vitamins, minerals, water. -MyPlate: half of plate is fruits & veggies; water should be mainstay of diet in older adults

Dysphagia

Difficulty swallowing; very common in older adults -After the age of 50, 20% have some degree of dysphagia. -Begins early; not necessarily due to any underlying condition, can just be due to aging. Things like *loss of muscle tone can be leading to this* -Up to 60% of LTC residents have some degree of dysphagia -Cause can be behavioral, sensory, or motor. Can result from a stroke Complications: 1. Weight loss 2. Malnutrition & dehydration 3. Aspiration pneumonia -*aspiration is a serious complication of dysphagia & can cause pneumonia --> sepsis --> 4. death*.

More older adults die from _____ than from all other natural disasters combined

Excessive heat Hyperthermia is caused from excessively hot environment - *can't have hyperthermia in response to infection*

Fall prevention interventions

Fall risk reduction programs: 1. Fall bundles -Arm bands, signs, education, risk assessment, footwear, assisted toileting 2. Environmental modifications 3. Assistive devices 4. Safe client handling 5. Wheelchairs 6. Alarms/motion sensors

________ is a major complication of constipation. It's especially common in incapacitated & institutionalized older people & those who require narcotic medications.

Fecal impaction -*common in those who live in institutions & long term care facilities bc they may not be moving as much* Manifestations & complications: 1. Malaise 2. urinary retention 3. increased temp 4. incontinence 5. cognitive decline 6. hemorrhoids 7. intestinal obstruction *Paradoxical diarrhea, caused by leakage of fecal material around the impacted mass, may occur & cause person to think that they are having a BM.*

Yellow, brown nail. Flaking/erythema of skin of the feet. Most important intervention is to keep feet clean and dry.

Fungal infections

What is the priority intervention for heat stroke?

GET THEM OUT OF THE HEAT - want to treat the underlying cause

Falls are considered what type of syndrome?

Geriatric syndrome -*Falls are a SYMPTOM of a problem* -1/3 of adults 65 and older will fall each year; 10% will sustain some type of serious injury (hip fracture, traumatic brain injury) & can lead to death *Fallophobia is the fear of falling causing limitations in function* -provide general education about preventing falls & proper body mechanics for walking to those who have this fear

Role of assistive technology

Gerotechnology term used to describe *assistive technologies to help older people have a better QOL & stay in their homes longer* -"Smart Homes" -Telemedicine & "smart medical homes" - monitor gait, behavior, & sleep -Environmental control systems -"Smart carpet" - detects gait abnormalities -Remote-control monitoring systems - auto lights, watering plants -Motion and pressure sensors - detects movement -Robotic technology -Facial recognition and memory aids *things to possibly educate people about if they're having issues*

Permanently flexed toe. Custom shoes or surgery is the treatment.

Hammer toe

Painful, vesicular rash, over a dermatome. Teach pt to get vaccine starting at age 60.

Herpes zoster (shingles)

Assessment of mood - 3 tools

Important to assess mood -with older adults, *new onset depression is NOT uncommon* Untreated depression can lead to more *functional impairments, prolonged hospitalizations, decreased QOL, & increased morbidity* Tools to assess mood: 1. Geriatric Depression Scale 2. Centers for Epidemiologic Studies Depression Scale 3. Cornell Scale for Depression in Dementia

Safety & security

Increasing vulnerability to environmental risks and mistreatment by others as older adults become less physically or cognitively able to cope or recognize real or potential hazards -*at a higher risk for being physically & emotionally assaulted* A safe environment allows an older person to live without fear of attack, accident, or imposed interference Sensory deficits can impair the individual's awareness of dangerous conditions or imminent threats -*impaired hearing, vision, or smell increases persons risk for injury*

______ is disturbed sleep in the presence of adequate opportunities and circumstances

Insomnia -diagnosis of insomnia requires that the person has *difficulty falling asleep for at least 1 month* Classified as primary & comorbid 1. primary insomnia: implies that no other cause of sleep disturbance has been identified 2. comorbid insomnia: more common & is associated with psychiatric & medical disorders & medications Medications & substance instigators: 1. *Drugs & alcohol account for 10-15% of insomnia* -alcohol causes bad quality sleep; stay in earlier sleep stage 2. Meds: SSRIs, antihypertensives, anticholinergics, diuretics, stimulants, etc -remember to first do an assessment of meds & find alternatives if necessary -times of day that meds are given can also contribute to sleep problems *Eliminate the underlying cause of the insomnia*

Loss of driving privileges

May have loss of driving privileges due to physical limitations or dementia -Not always individual's choice A life-changing event contributes to: 1. Social isolation 2. Increased depressive and anxiety symptoms 3. Decreased QOL 4. *Increased risk of nursing home placement* -Associated with loss of autonomy, pleasure, competence, and self-worth -Must include plan for alternate transportation with family, caregivers, or community resources

Exercise guidelines

Older adults need at least: 1. 2 hours and 30 min (150 min) of moderate intensity aerobic activity (brisk walking, swimming, bicycling) AND 2. muscle strengthening activities on 2 or more days that work all major muscle groups (legs, hips, abdomen, chest, shoulders, and arms)

Older Americans resources & services (OARS)

Overall more comprehensive assessment of: 1. Social resources 2. Economic resources 3. Mental health 4. Physical health 5. ADLs *Aids in establishing degree of need* -Rating of excellent to completely impaired

Causes most of aging cosmetic problems. Most important intervention is to use sunscreen.

Photo damage

Pressure ulcers

Pressure ulcers, like pain, are a *BIG indicator of nursing care.* When a person's pain is not controlled or person develops a pressure ulcer, that always reflects directly back on the nurse. Highest incidence reported in: 1. hospitalized or institutionalized older adults -sometimes very difficult to prevent in older adults bc they're cachexic & skin is very fragile, but still need to be doing interventions & documenting them 2. vulnerable adults undergoing orthopedic surgeries -in surgery for long periods of time in the same position, increasing the risk for pressure ulcers. -also, when a person goes to the OR, they're moved around a lot, increasing risk for snags, tears, & friction -Pressure ulcers can significantly impair recovery & rehab & impact QOL -*increased risk of mortality, mainly due to infection* -high prevalence of healthcare litigation -CMS (medicare/medicaid) now considers pressure ulcers a preventable adverse event & do not reimburse treatment for pressure ulcers acquired during admission

Itchy skin. Use fragrance free products. Lotion

Pruritis

Thin, fragile skin. Teach person to wear long sleeves & protect skin from trauma, especially their arms

Purpura (purple splotches on arms; essentially bruises)

In regards to use of restraints on older adults, what is the goal for care?

Restraint-free care -should not be used to manage behavior symptoms -treat the underlying problem

Pressure ulcer risk factors (4) & systemic prevention (5)

Risk factors in older adults: 1. skin changes 2. comorbid illnesses 3. nutritional status 4. reduced mobility Systematic prevention 1. eliminate friction & irritation 2. reduce moisture 3. turning 4. propping 5. promote nutrition

Crimes against older adults

Risks and Vulnerability: 1. Living alone 2. Memory impairments 3. Loneliness 4. *Older people are more likely to be victims of consumer fraud and scams that include telemarketing fraud, e-mail scams, undelivered services* Fraudulent schemes against alders: -Trusting elderly persons may be duped into giving money to pen pals, Internet acquaintances, phony religious causes, new acquaintances who "need help" -Door-to-door contractors, IRS Impersonators, Medical fraud -*need to teach people to be aware of these things*

Waxy, raised lesion. No prevention.

Seborrheic keratosis

What is considered the barometer for health?

Sleep -good measurement of a person's overall health Aging is associated with: 1. decreased sleep quality 2. sleep disorders (apnea, insomnia) 3. Circadian rhythm responses diminished -increase in stage one of sleep (lightest level of sleep; between being awake and falling asleep) & less REM (restful sleep stage) 4. Longer to fall asleep 5. Frequent awakenings 6. Increased napping during the day Must assess sleep patterns *Common myth that older adults don't need as much sleep as younger adults but this is not true - older adults still need about 8 hrs of sleep per night.*

_______ is periods of not breathing while sleeping

Sleep apnea Signs & symptoms: 1. excessive daytime sleepiness 2. snoring, gasping, choking 3. headache, irritability -*symptoms often fit stereotypical characteristics of an older adult*, but should not blame on age & need to further investigate 70% of men & 56% of women 65 and older have obstructive sleep apnea (OSA) -many don't have diagnosis & think they just snore a lot -*caused by a decline in the tone of the upper airway muscles,* which *allows the upper airway to close more easily* -sometimes tongue is involved & can cover the airway; that's why when a person is lying on their back they have more episodes of apnea & snoring Treatment: 1. limit/stop alcohol & sedative use 2. lose weight (being overweight contributes to OSA) 3. smoking cessation 4. CPAP (continuous positive airway pressure)

Age related changes in bowel causing constipation

Small intestine: 1. villi become broader, shorter, & less functional; blood flow decreases 2. Proteins, fats, minerals (including calcium), vitamins (esp. b12), and carbs (esp. lactose) are absorbed more slowly & in lesser amounts Large intestine: 1. slowed peristalsis, blunted response to rectal filling, increased collagen deposition leading to dysmotility, fibro-fatty degeneration & increased thickness of the internal anal sphincter

Stages of pressure ulcers

Stage 1 - red, non-blanchable skin Stage 2 - top layer of skin is gone Stage 3 - down to deeper tissues; fat, muscle Stage 4 - bone is visible *Unstageable if pressure ulcer has eschar or necrotic tissue* -once it's cleaned out & necrotic tissue is removed, then it can be staged -if eschar is present, it is at least a stage 2

_____ is the most common cause of sepsis in older adults

UTI -*Often asymptomatic in older adults*. May not have the classic signs such as frequency, burning, urgency. -Cognitively impaired may not report symptoms -Atypical symptoms (not typical, but common in this age group): 1. *mental status change (sudden onset confusion*; this is why it's important to have baseline mental status) 2. decreased appetite 3. incontinence -*Normal for older adults to have asymptomatic, uncomplicated bacteria in urine.* -partially has to do with the change in urine's pH that bacteria can live there more easily -UTI happens when bacteria adheres to the bladder wall & then begins to cause symptoms UTI algorithm: assessment & treatment for UTI in nursing homes

Dry, cracked, itchy skin. Increase fluid intake. Use gentle, moisturizing soaps

Xerosis (condition which can lead to itchy skin)