Gero exam 4 prep

Age related changes: SLEEP AND REST Sleep Quantity and Quality: Circadian Rhythm:

--Sleep efficiency, which is the percentage of time asleep during the time in bed, begins to decline even in healthy adults after the age of 50. --This diminished sleep efficiency is attributed both to prolonged sleep latency, which is the time required to fall asleep, and to an increased number of awakenings during the night. --The circadian rhythm, or biological clock, help determine sleep patterns. The sleep-wake circadian rhythms usually causes adults to become sleepy between 10 pm and midnight, and to awaken feeling rested between 6 am and 8 am. With age, an advanced sleep phase causes older adults to become sleepier earlier in the evening and awaken earlier in the morning. These age-related changes can also be exacerbated if there is lack of exposure to bright light. Body functions that have a circadian pattern include thermoregulation, sleep-wake cycles, and secretion of many hormones, including cortisol and melatonin.

RISK FACTORS THAT AFFECT DIGESTION AND NUTRITION Environmental Factors (4)

-A noisy or crowded dining room may have a negative impact on food enjoyment and consumption -weather conditions -transportation -environmental conditions and packaging trends in the grocery store

Age-Related Macular Degeneration s/s Nursing Interventions

-AMD is the leading cause of severe vision loss and blindness in people over age 55 in the US. -AMD causes gradual progressive loss of central vision, distorted straight lines, and blurred vision. -AMD is significantly associated with blindness, hip fractures, depression, and residence in a long-term care facility. Prevention includes avoiding cigarette smoke and taking an eye vitamin such as occuvite. Dry MD is death of the photoreceptors, it progresses slowly and usually does not cause blindness. Wet MD is from the formation of blood vessels in the choroid that hemorrhage in to the subretinal space. This is rapid and severe vision loss. -often occurs in both eyes, but again, not necessarily at the same rate. The loss of central vision can significantly affect reading, driving, watching TV, recognizing people, and performing self-care. People with AMD should test their vision daily with an Amsler grid to notice sudden changes. An evidence-based intervention for prevention of AMD progression is the daily use of a nutritional supplement that contains all the following: Vitamin C 500 mg Vitamin E 400 IU Zinc oxide 80 mg Cupric oxide 2 mg Beta carotene 15 mg or lutein 10 mg and zeaxanthin 2 mg

Communication with Hearing-Impaired Older Adults: Communication can be enhanced with the following techniques:

-Avoiding or eliminating background noise, such as with window treatments -Sit or stand directly in front of and close to the person so they can read your lips -Talk toward the better ear -Make sure the person is paying attention -Speak distinctly, slowly, and directly to them -Do not exaggerate lip movements, it is harder to read lips then -Avoid chewing gum -Do not try to talk louder, instead talk lower in a loud voice -Use short sentences if possible -Use nonverbal and written communication

RISK FACTORS THAT AFFECT DIGESTION AND NUTRITION Psycho-social Factors (4)

-Change in mealtime companionship -socioeconomic inequality -social isolation -living alone

What types of foods are important to consume as you age?

-Diets rich in omega-3 fatty acids, such as those found in fish, are important for promoting healthy aging and preventing age-associated chronic conditions -The Mediterranean-style diet is considered the "gold standard" for healthy aging and increased life expectancy -Whole grain and fiber-rich -Rich in plant-based and unprocessed food -Increased intake of ,vegetables and legumes,fat-free and low-fat milk foods and beverages that are lower in sodium. -Fewer calories from solids, fats, and added sugars

Functional consequences of hearing loss in older adults

-Diminished cognitive function -Functional decline -Loneliness -isolation -diminished participation in social activities -Diminished emotional vitality, defined as a high level of happiness and sense of personal mastery and low levels of anxiety and depressive symptoms -Increased prevalence of depression -Decreased autonomy -Increased dependence on others Also, ikely to be less responsive when warning signals are sounded for fires, ambulances, and other emergencies

Risk factors that effect SLEEP Pathophysiologic Factors: (also see image)

-Diseases -Pain -Medication -Some diseases are exacerbated during REM sleep. -Muscle cramps often occur at night that interrupt sleep, including Restless Leg Syndrome (RLS) and periodic limb movements in sleep (PLMS). RLS most often occurs between 11pm and 3 am

Risk factors that effect SLEEP Environment:

-Environmental factors can also affect sleep. In an institutional setting, it is often not quiet or private, especially in a shared room, that can interfere with sleep. -Older adults may have relaxation routines before bed, such as reading or listening to music that might not be allowed. -Also, residents often have to adjust their sleeping schedules around the schedules of their caregivers, nurses, CNAs, dietary, etc. in a nursing home or of a caregiver at home who may still be working of have other responsibilities. -Environmental temperatures can also affect sleep. The older adult may have a malfunctioning heating and cooling system, or they may not be in control of the temperature. Hot temperatures can be especially difficult for menopausal women with hot flashes. -In 40's, people become more sensitive to noise so older adults may be awakened from environmental noise. -Excessive lighting in the environment, such as in the hallway or for a roommate can disturb circadian rhythms and disrupt sleep. In addition, a lack of bright light during the day can lower melatonin production which is needed for sleep. -Older adults who are caregivers can also have their sleep altered if they need to provide care during the night. -Fear, loneliness, can also disrupt sleep for older adults

1. The following are some of the consequences of visual impairment that studies have identified: 2. Age-related vision changes most directly influence the following activities:

-Higher prevalence of falls, injuries, and fractures -Higher prevalence of chronic health conditions -Higher mortality rates, possibly due to accidents and falls -impaired ability to self-manage chronic conditions -Diminished participation in family, social, and community activities -Poor quality of life Increased risk of being admitted to a long-term care facility ----------------------------------------------------------- -Getting outside -Driving a vehicle -Shopping for groceries -Going up and down stairs -Maneuvering safely in dark or unfamiliar environments -Seeing markings on clocks, radios, thermostats, appliances, and televisions -Reading newspapers, directories, small-print signs and posters, and labels on food items and medication container __________________________________________________________________________ -Effects on Quality of Life; Older adults with impaired vision commonly experience anxiety, depression, and lower levels of psychological well-being, particularly when the visual loss causes functional limitations--fear going blind. Fear of falling. -Effects on driving: night driving

Functional Consequences affecting Urinary Wellness:

-Impaired renal function can affect calcium absorption and predispose a healthy older adult to hyponatremia and hyperkalemia. -Age-related changes affect the compensatory mechanisms that maintain fluid and electrolyte balance and maintain pH balance (unable to maintain) -The kidney respond less to ADH and cannot concentrate urine, with age. Therefore, in older adults: -The risk for dehydration and hypovolemia from diuretics is greater -Fluid and electrolyte imbalances are more likely during physiologic stress, such as surgery or infection -It is more difficult to compensate for fluid loss with fever inducing illnesses increasing the risk for volume depletion -Increased ADH secretion (from medication or illness) is more likely to cause fluid overload and hyponatremia -There is a higher risk for drug interactions and adverse reactions, especially in water-soluble mediations Effects on Voiding Patterns: -With age, the bladder holds less, does not empty completely, and contracts while filling all causing older adults to need to void more frequently and to have a shorter amount of time from when the urge to void is felt to actually needing to empty the bladder. ****MAKE SURE THEY STAY ON THE TOILET FOR ANOTHER MINUTE OR TWO -Since the bladder does not empty completely, older adults have a higher risk for UTIs ****MAY STRAIGHT CATH -Age-related changes can cause older adults to need to void more at night than during the day and medical conditions and medications can further increase frequency and nocturia. Nocturia can disturb sleep, increase nighttime falls, and decrease quality of life. ************AVOID FLUID BEFORE BED

AGE-RELATED CHANGES THAT AFFECT DIGESTION AND EATING PATTERNS Esophagus and Stomach (think about malabsorption of nutrients)

-In older adults, the esophagus stiffens and peristaltic waves decrease -Slowing of gastric emptying Consequences of reduced gastric acid include malabsorption of increased bacterial overgrowth in the intestinal tract and malabsorption of iron, calcium, and vitamin B12

Guidelines for Care of a Hearing Aid

-Keep a fresh battery available but do not purchase batteries more than 1 month in advance. -Turn off the hearing aid before changing the battery. Remove the battery or turn off the aid when not in use. -Clean the aid weekly, using warm, soapy water for the earmold and a toothpick or pipe cleaner for the channel. -Never use alcohol on the earmold because this will cause drying and cracking. -Check the earmold for cracks or scratches. -Avoid extreme heat, cold, or moisture. -Avoid exposure to chemicals, such as hairspray or permanent solutions. -Avoid dropping the aid on a hard surface; when handling it, keep it over a soft or padded surface.

Risk Factors That Affect Thermoregulation: Behaviors Bases on Lack of Knowledge:

-Lack of knowledge may prevent older adults from taking proper precautions such as adjusting the thermostat when on a fixed income or adding or removing clothing to compensate for temperature changes. -Also, older adults may not have a elevated temperature of 99 degrees or higher with an infection (due to lower basal temp or no elevation of temp) and if caregivers assume no fever means no infection, infections could go undetected.

Role of Nurses in Assessment and Interventions: HIV/AIDS

-Nurses have important responsibilities with regard to promoting wellness for older adults with HIV, including addressing related psychosocial needs -Nurses need to know that HIV initially presents as a nonspecific viral illness with symptoms similar to the flu or mono, such as fever, rash, malaise, myalgia, and pharyngitis. -Teach about safe sex -Inform on proper care/safe practices with multiple partners -Encourage early screening/detection/testing when risk factors are present. -These symptoms subside after 2-3 weeks, even without treatment. -Antibodies do not appear in the blood until 3-6 weeks after the infection. Without treatment, AIDS will develop and lead to death in 2-3 years, or sooner. With treatment, it can take 15 years or longer to progress to AIDS. -Older adults are not routinely tested for HIV, therefore diagnosis is often at a later stage. Nurses need to assess risk factors and determine if screening should be encouraged.

NURSING INTERVENTIONS to promote Urinary wellness List all the nursing classifications (13)

-challenge myths about urinary incontinence, address attitudes of resignation, and teach self-care interventions. -nurses have important roles in teaching about medical interventions and suggesting referrals for appropriate evaluation and treatment. The following Nursing Interventions Classifications terminology is pertinent to promoting urinary continence and addressing the associated psychosocial consequences: 1. Biofeedback 2. Emotional Support 3. Environmental Management 4. Fluid Management 5. Health Education 6. Pelvic Floor Muscle Exercise (PFME) 7. Prompted Voiding 8. Referral 9. Self-Esteem Enhancement 10. Urinary Bladder Training 11. Urinary Elimination Management 12.Urinary Habit Training 13. Urinary Incontinence Care

AGE-RELATED CHANGES THAT AFFECT DIGESTION AND EATING PATTERNS -Oral Cavity changes? (6 major changes) -Xerostomia affects nutrition and gastrointestinal function because it is associated with all the following......? (7 affects)

1. -With increased age, the tooth enamel becomes harder and more brittle -nerve chambers become shorter and narrower. -the teeth are less sensitive to stimuli and more susceptible to fractures. -loss of elasticity,atrophy of epithelial cells, diminished blood supply to the connective tissue -neuromuscular change that can have a small effect on mastication and swallowing. -xerostomia (i.e., decreased salivation and uncomfortable dry mouth) 2. The most common causes of xerostomia in older adults are chronic conditions : (e.g., Sjögren syndrome, malnutrition, renal dialysis), radiation to the head and neck, and adverse medication effects.) Xerostomia affects nutrition and gastrointestinal function because it is associated with all the following- -Altered chewing, swallowing, speaking -Dry, cracked lips -Burning sensation in mouth and lips -Dry mucous membrane -Diminished taste, especially for bitter and salty flavors -Dental caries and increased plaque production -Gingivitis and periodontitis

Interventions to promote healthy digestion and nutrition: 1. Addressing Risk Factors that Interfere with Digestion and Nutrition: 2. Promoting oral and dental health: 3. Promoting Optimal Nutrition and Preventing Disease:

1. Addressing Risk Factors that Interfere with Digestion and Nutrition: -If an older adult experiences early satiety, they may benefit from 5 small meals throughout the day as opposed to the traditional 3 large meals. -Encourage patients to sit upright during eating and half and hour to one hour after eating to compensate for slowed swallowing. -If someone has difficulty procuring or preparing food, nurses can help identify community resources. Meals on wheels and similar services not only provide inexpensive and nutritionally balance meals, but also social interaction when the food is dropped off daily. -Nurses could also help arrange transportation to the grocery store for quality food if the local convenient store is where they currently shop. -Home environments can be adapted if high cupboards are difficult to reach. -Good oral hygiene should be done before eating to enhance taste. To season foods, use a low-Na or no-Na flavor enhance, such as Mrs. Dash. Penzeys spices has a lot of no-Na spices. Be careful with salt-substitute, it is KCl, and can cause hyperkalemia. - have fluids and nutritious snacks easily accessible. -Educate on constipation and a high fiber diet. Bran cereal is a good way to prevent constipation. -Along with drinking 8-10 glasses of noncaffeinated liquid, including water and fruit juice everyday. -Get regular exercise and avoid laxatives and enemas. -Encourage decreasing alcohol consumption if too many calories are coming from nutrient-poor alcohol. -Encourage vitamin supplements for nutrient deficiencies. 2. Promoting oral and dental health: -Nurses can emphasize the importance of obtaining dental care every six months and help older adults set up dental care. Home dental care is available is some cities for home bound older adults. -If the older adult complains of xerostomia, assist in setting up a medical evaluation to identify contributing factors such as medications or diseases. -For dependent older adults, good oral care is essential. Staff education may be needed. -If alcohol based mouthwash is used, dilute it to half strength with water to prevent the drying effects of the alcohol. -If the person has dentures, good oral care of the dentures is needed as well as the mouth. If the person has a G-tube, oral care is required every 4 hours. -If dentures are worn, remove them every night and soak in water. Clean them before putting them back in the next morning. -For independent older adults, nurses provide education on oral care. It should include daily flossing and twice daily brushing of all tooth surfaces. Use a soft bristled toothbrush and fluoride toothpaste. Mouthwash is to be used in conjunction with brushing, not in place of. Avoid alcohol based mouthwash. -Limit sugary substances kept in the mouth, such as gum or hard candy, and rinse your mouth or brush after sugary foods. 3. Promoting Optimal Nutrition and Preventing Disease: -Nurses teach about basic nutritional requirements and dietary guidelines. -Older adults should increase their intake of whole grains, dried peas and beans, all fruits and vegetables, low-fat or fat-free milk and milk products; replace solid fats with oils; consume less sodium and saturated fats; consume less food and beverages with added sugar, solid fats, and alcohol.

FUNCTIONAL CONSEQUENCES DIGESTION AND NUTRITION 1. Age related changes and conditions/diseases? 2. Ability to Procure, Prepare, and Enjoy Food--how is this problematic? 3. Changes in oral function? 4. Nutritional status and weight changes? 5. Quality of life?

1. Age-related changes and conditions that may interfere with these activities include: -vision impairments -arthritis - anything that limits mobility, balance, or manual dexterity 2. Ability to Procure, Prepare, and Enjoy Food: requires cognition, balance, mobility, manual dexterity, and the five senses. -Procurement requires getting to the grocery store, pushing a shopping cart, reaching for food items high on a shelf, reading small print on shelves and packages for cost and nutrition, and coping with glare and bright lights in the store. -Preparing food requires cutting food items, measuring ingredients, carrying food and liquid without spilling, standing for long periods, reaching for items in cupboards, using the stove or oven, and reading temperature controls. (Grandma baking cookies and not having ingredients after running a restaurant for years) -Enjoying foods relies on the senses. Color, taste, or smell affect food appeal. A lack of smell or taste can increase condiment use, such as salt and sugar. And can also decrease the ability to tell if food is spoiled. -Food choices can also be impacted by the quantity and quality of teeth or dentures. Changes in Oral Function: Older adults with poor oral health are likely to avoid fresh fruits or raw vegetables and meat and are at risk for nutritional deficiencies Nutritional Status and Weight Changes: --Common nutrient deficiencies in older adults include zinc, calcium, fiber, magnesium, potassium, most B vitamins, and vitamins C, D and E --Protein-energy malnutrition (or protein-calorie malnutrition) is when the person is not getting the required protein and calories needed daily. This is common in frail older adults. Symptoms include weakness, lethargy, unintentional weight loss, loss of muscle mass, significant loss of subcutaneous fat, and an inability to respond to surgery or infection. -BMI is commonly used as a standard for ideal weight, under weight, over weight, and obese. However, waist circumference is a better indicator for chronic conditions, such as diabetes and cardiovascular diseases. Quality of Life: Food related activities are often the focal point of holidays, celebrations, and family gatherings. Older adults who no longer enjoy eating may withdraw from these activities. And, when these activities are no longer part of their lives, they may lose interest in eating. Malnutrition, dehydration, and electrolyte imbalances can cause mental status changes and memory impairment. It is important for the older adults quality of life that the mental changes are not attributed to age or dementia when there is an underlying treatable and reversible metabolic imbalance

Dysphagia 1. What can cause Dysphagia? 2. List some risks associated with dysphagia? 3. Symptoms of Dysphagia? 4. Recommendations for Nursing Assessment?

1. Diminished muscle strength and function, reduced tissue elasticity, and impaired dental status 2. In addition to neurologic conditions, the following factors can increase the risk of dysphagia: -frailty -altered mental status -certain medications (e.g., anesthetics, anticholinergics, sedatives, psychotropics, antihistamines, amiodarone). -increases the risk of malnutrition, -dehydration -aspiration/aspiration pneumonia 3. -drooling, coughing during meals, voice changes following meals, gurgling sounds in the throat, upper respiratory tract infection, wet lung sounds, or packing food in the cheeks. -Signs and symptoms of aspiration pneumonia include delirium, fever, chills, elevated respiratory rate, pleuritic chest pain, and respiratory crackles 4. Nursing assessment includes the following observations: -level of consciousness? -voluntary cough? -voice quality, and control of secretions?

Risk Factors That Affect Urinary Wellness—(cont) 1. Functional Impairments and Environmental Condition: 2. Pathologic conditions? (Men and Woman) 3. Other conditions that cause urinary incontinence.?

1. Functional Impairments: ---With a shorter time between the urge to void and the need to void, any delay in reaching the bathroom can cause incontinence -Slower ambulation -difficulty with manipulating clothing, -cognitive impairment, or restraints can all delay reaching the bathroom. Therefore, a dependency on ADLs often leads to incontinence. 2. Pathologic Conditions: Usually gender specific ---Pelvic floor dysfunction: Weakening or stretching of pelvic floor muscles and in women can cause pelvic organ prolapse which is a condition where the vaginal wall bulges. Contributing factors obesity, increased age, of the vaginal tissue with diminished resistance to pathogens. ---BPH: Common cause of voiding problems in men. -Progressive BPH, result urine retention, increasing risk for bacteria and infection. Eventually the ureter and kidney are affected, diminished GFR and uremia may develop. -Men experience nocturia , decreased urine flow, incomplete bladder emptying and urinary urgency and frequency. ****************PELVIC FLOOR EXERCISES FOR MEN AND WOMEN 3. Other conditions that cause urinary incontinence. --Dementia may cause a lack of perception to find the appropriate facilities. -The GI track that can cause issues are GE, constipation, and fecal impaction. -Others obesity, diabetes, ETOH, MS, Parkinson's, CVA, COPD, metabolic disturbances, can induce diuresis and hypercalcemia. Also, delirium and acute illness.

Recommendations for Nursing Assessment: CAUTI's 1. -Appropriate indications for use of an IUC 2. -S/S for those with a CAUTI?

1. Identify appropriate indications for use of an IUC: -preoperative care -prolonged surgery -monitoring during surgery or critical illness -major trauma patients -urinary retention or obstruction -urinary bladder irrigation -pressure ulcer management -comfort care during terminal illness 2. Assess for the following indications of CAUTI: -Fever over 38°C, -Suprapubic tenderness -Costovertebral angle pain or tenderness -Positive blood culture with the same organisms as in the urine -Dysuria or urinary frequency if the catheter has already been removed Reassess patients with IUCs at every shift change or at least daily and apply criteria for continuing the use of the catheter.

Risk Factors That Affect Urinary Wellness 1. Misconceptions 2. Fluid intake and dietary 3. Medications 4. Environmental factors 5. Myths and misunderstandings 6.Changes Affecting Control over Socially Appropriate Urinary Elimination:

1. Misperceptions and Lack of Knowledge: -Even though increased age is a risk factor for urinary incontinence, it is a major mistake to perceive incontinence as an inevitable and irreversible consequence of aging. promote the use of absorbent products as a substitute for more time-consuming interventions, such as providing assistance with toileting 2. Fluid intake and dietary factors -Limited fluid intake perceived as maintaining continence can have opposite effect—leads to lower urinary tract symptoms Inadequate fluid intake causes urine to be more concentrated, causing bladder irritability with difficulty maintaining continence 3. Medication Effects: -Loop diuretics -Terazosin used for BPH can cause urethral relaxation and stress incontinence. It is important to identify the causes of incontinence be identified early. -Anticholinergics can cause cognitive and other functional impairments, which can interfere with voluntary control over urination. -Increase ADH secretion, effects that predispose older adults to hyponatremia. Meds that stimulate the ADH include ASA, narcotics, acetaminophen, antidepressants, barbiturates.. Environmental Factors: Prevents older adults to void when mobility issues are present. Other obstacles are stairs, no grab bars and railings, and toilets that are not the right height Myths and Misunderstandings: About 80% of urinary incontinence can be cured. -caregivers do not understand the difference between transient and chronic urinary incontinence. -If an episode of incontinence occurs and staff assume it is chronic, and give the older adult absorbent pads, they send the message that they do not expect the person to have voluntary control of their bladder. -Older adults are likely to behave according to the expectations of the caregivers and incontinence is inevitable. -Another common myth that older adults have is that if they limit their fluids, they won't become incontinent. In reality, limited fluid intake or dehydration can cause incontinence. If bladder fullness is not reached from a lack of fluids, there will not be an urge to void even though the bladder is not empty and will lead to urinary leakage. It also irritates the bladder causing contractions and incontinence. Changes Affecting Control over Socially Appropriate Urinary Elimination: -To urinate, an older adult needs to find a private bathroom to use, they need the cognition, balance, mobility, coordination, visual function, and manual dexterity to get there and use the bathroom in time from the urge to void to the actual need to void. -For older men, it becomes more difficult to use a urinal and can be more difficult to find a toilet to use. -The attitudes and behaviors of caregivers can significantly influence urinary elimination patterns as well. Where do they encourage the older adult to urinate? In bed? In a bed pan or in depends? Get up to the toilet? ****EDUCATE CAREGIVERS. PAY ATTENTION TO SKIN BREAKDOWN

1. What are some barriers for nurses when implemeting interventions? 2.Common barriers to use of hearing aids include all the following:

1. Nurses can identify barriers, such as : -cost -effectiveness, or appearance to create appropriate interventions. -They may need assistance finding a audiologist, or don't have transportation to get there. Assessing the barriers is just as important as assessing the hearing. 2. Common barriers to use of hearing aids include all the following: -Perception that hearing aids are of little use -Concerns about cost -Difficulty arranging for evaluations -Lack of transportation for appointments -Embarrassment about the visibility of hearing aids -Lack of manual dexterity necessary for use of smaller hearing aids

Nursing Assessment of Urinary Function: 1. What will you ask the patient/assess for? 2. Talking with Older Adults about Urinary Function? 3. Identifying Opportunities for Health Promotion? 4. Lab Values?

1. Nursing assessment •Risk factors of overall urinary function •Potential for incontinence •Signs and symptoms of dysfunction with elimination •Fears and attitudes 2. Talking with Older Adults about Urinary Function: A person's attitudes and feelings can influence whether they want to openly discuss urinary function. Nurses learn to discuss the topic easily, but a gender or age difference can make a older adult uncomfortable. Also, communication barriers, such as hearing impairment, can limit a person's ability to discuss the topic. In addition, if they see their incontinence as inevitable, they may not give information needed to correct the underlying cause. - Words such as urination or incontinence may not be known. -Also, use terms such as depends or briefs, not diapers used for babies. ----If the older does admit to incontinence, ask about what interventions are used and how it affects their daily activities or social life. 3. Identifying Opportunities for Health Promotion: -A bladder diary, or bladder record is a method of obtaining information about urinary elimination patterns. It should include fluid intake, times of urination, and any factors that affect continence. -Identify assistive devices that could benefit the person, such as an elevated toilet seat, grab bars, or using a urinal or commode. 4. Lab Values: Data from a UA or blood chemistries can be helpful. For a UA, older adults have a high specific gravity limit of 1.024 and slight proteinuria is normal. Other than that, the UA should be WNL. Blood chemistries give you electrolyte levels, creatinine and BUN and if there is an albumin level, a GFR can be calculated.

RISK FACTORS THAT AFFECT DIGESTION AND NUTRITION Oral Care Factors that contribute to poor oral care? (8) Consequences of poor oral care? (8)

1. Some factors that contribute to inadequate dental care include: -low income -less education -lack of transportation - lack of dental insurance -high cost of dental services -more pressing health concerns -inaccessibility of service -Inadequate oral care, (as indicated by greater bacterial plaque and gingival bleeding, is common in older adults who are cognitively impaired) 2. Adverse effects of poor oral health include -malnutrition -dehydration -periodontal disease -respiratory infections (e.g., pneumonia and aspiration pneumonia) -joint infections -cardiovascular disease -poor glycemic control in diabetes -increased risk of stroke and heart attack

NURSING INTERVENTIONS to promote Urinary wellness 1. Teaching about Urinary wellness? 2. Promoting continence and alleviating incontinence? 3. Biofeedback and stimulation? 4. Urinary control devices? 5. Continence training? 6. Environmental modifications? 7. Medications? 8. Surgical procedures?

1. Teaching about Urinary Wellness: -Since older adults do not preserve water and sodium as well, teach them about the importance of staying hydrated, increasing fluid intake with exercising or in hot and humid environments, using fans or AC, avoiding alcohol, caffeinated, or carbonated beverages. -If kidney function is diminished, medication doses should be adjusted to prevent adverse medication affects. -Teach older adults that incontinence is not inevitable and if present to identify risk factors. -Teach that limiting fluid intake will not prevent incontinence. -Prevent dehydration by drinking fluids (nonalcoholic, noncaffeinated, noncarbonated) even when not thirsty. 2. Promoting Continence and Alleviating Incontinence: -Pelvic floor muscle training: Kegel exercises *** First line intervention for men and women with stress or mixed incontinence. Can also help with urge incontinence. It improves urethral resistance through active exercise of the pubococcygeal muscle. -Full effects take 3-6 months of regular exercise and then must be maintained daily. 3. Biofeedback and Stimulation: -nerve stimulation used from stress, urge, or mixed incontinence by increasing sphincter tone and strengthening levator and periurethral muscles. - Sacral nerve stimulation surgically implants a neurotransmitter to send mild electrical impulses to the sacral nerves to improve continence by inhibiting involuntary bladder contraction and an increase in bladder volume. 4. Urinary Control Devices: -intravaginal or intraurethral devices for stress incontinence. They include plugs, valves, occlusive devises, or penile clamps. -Foleys are typically not considered a urinary control device because of the high incidence of UTIs associated with them. 5. Continence Training: -can be for the patient or the caregiver. The goal is to achieve a continent interval of 2-4 hours between voiding. -The bladder needs to be able to hold at least 150 mL for this to be effective however. Once a voiding pattern specific to that person is created, they should try to resist using the bathroom with every urge felt and stay on schedule. -Fluid intake of about 2000 mL/day is important as well. 6. Environmental Modifications: -Become familiar with public places and where bathrooms are before the need to urinate. -Bedside commodes, elevated toilet seats, and grab bars can improve the ability to use the toilet. 7. Medications: -The most common are antimuscarinic agents, such as oxybutynin, ditropan, detrol, vesicare, and enablex. People taking these meds need to be assessed for cognitive impairment or mental status changes since these meds can cross the blood-brain barrier. -For men, with BPH, meds such as Flomax, Hytrin, and Proscar are used. 8. Surgical and Minimally Invasive Procedures: used to reposition the urethra so the pelvic floor can squeeze it more effectively. -An artificial sphincter can be placed with an inflatable cuff. A wire mesh stent can hold open the urethra for men with BPH.

PATHOLOGIC CONDITION AFFECTING HEARING: 1. TINNITUS? 2.What are some underlying conditions that can cause tinnitus? 3. How can Tinnitus be exacerbated?

1. Tinnitus: ringing, roaring, blowing, buzzing, or other types of noise that do not originate in the external environment 2. Tinnitus is a symptom of an underlying condition, such as impacted cerumen otosclerosis, Ménière disease HTN cerebrovascular disease inflammation or allergies of nose or adjacent structures. Most often, it occurs in conjunction with sensorineural hearing loss 3. Exacerbated with caffeine, alcohol, or nicotine

Risk Factors that Affect Sexual Function: 1. Attitudes and behaviors of families and caregivers 2. Effects of dementia on sexual expressions

1. •Affect sexual wellness expressly if dependent 2. •Loss of sexual desire •Hypersexuality •Sexually inappropriate

Risk Factors That Affect Thermoregulation 1. Conditions That Increase the Risk for Hypothermia? 2. Conditions That Increase the Risk for Heat-Related Illness?

1. Conditions that decrease heat production: -Inactivity -Malnutrition -Renal Failure -Stroke -Endocrine disorders/Parkinsons -Neuromusculuar conditions; conditions that increase heat loss such as burns and vasodilation; and conditions that affect the normal thermoregulatory process including pathological conditions of the CNS, all increase the risk for hypothermia. Medications, particularly psychotropic drugs, and alcohol can suppress shivering or induce vasoconstriction causing a risk for hypothermia. 2. Risk for hyperthermia includes: -Increased internal heat production, such as with hyperthyroidism or diabetic ketoacidosis -The inability to respond to heat stress, such as with cardiovascular disease or fluid or electrolyte imbalances (dehydration) -Diuretics or medications that increase urine output; medications that interfere with sweating, including anticholinergics; or medications that interfere with peripheral vasodilation, such as beta- adrenergic blocking agents. -Excessive exercise -And while alcohol is a risk for hypothermia, it is also a risk for hyperthermia as a diuretic and in excess can increase heat production.

Pathologic Condition Affecting Digestive Wellness What is Constipation? Risk factors for constipation?

1. Constipation (make sure to look at medications!!) decrease in frequency, difficulty passing stool, incomplete passage of stool, or passage of extremely hard, dry stool, is one of the most common problems of digestion. People naturally have different frequencies for bowel movements ranging from three times a day to once or twice a week, but should not change with age. 2. Risk factors for constipation are: -decreased mobility -hypothyroidism -adverse medication effects including long-term laxative abuse -diet such as low fiber or fluids.

Risk Factors That Affect Thermoregulation: Environmental & Socioeconomic Influences?

: -Environmental temperatures can affect core body temperature, especially in adults age 75 and older. This is worsened by the loss of thirst sensation creating a greater risk for dehydration due to Insufficient fluid intake -Substandard living conditions -Diets low in protein and calories create additional risks. -Ventilation is needed in hot temperatures and heating is needed for cold temperatures. (No AC environments with poor ventilation and high levels of humidity and air pollutants) -Social isolation increases this risk as an older adult may not be able to self-report poorly controlled temperatures at home. -Homelessness is another concern for older adults in hot or cold temperatures.

Nursing Assessment: Thermoregulation

Address the older person's baseline body temperature, any risk factors for altered thermoregulation, manifestations of hypothermia or heat-related illness, and febrile response to illness. Assessing Baseline Temperature: Body temperatures fluctuate throughout the day by 1-2 degrees, with lower temperatures while sleeping and even greater fluctuations with illness. Therefore baseline temperatures with normal fluctuations are necessary to know. With that it is important to document the route taken as that can be another variation. In the home setting, older adults can take their own temperatures at different times of the day for several days when feeling well to establish baselines. These baselines can also changes based on the seasons so many need to be done every few months in WI. This will help determine when there are increases in body temperatures earlier. Identifying Risk Factors for Altered Thermoregulation: Nurses can identify risk factors, including medications or conditions that put an older adult at a higher risk. Hypothermia is a risk when older adults, or the family they live with, keep the home cool in the winter. Hyperthermia is a risk when older adults do not have AC or good ventilation during a heat wave. (access to heat/cool vs. paying for it). Assessing for Hypothermia: -Cool skin in unexposed areas, such as the abdomen or buttocks can indicate hypothermia. They will not likely shiver or complain of being cold. Some thermometers do not read below 95 degrees and would not be appropriate to be used when hypothermia is suspected. .-Additional s/s are lethargy, slurred speech, mental changes, impaired gait, puffiness of the face, slowed or irregular pulse, low BP, slowed tendon reflexes, and slow, shallow respirations. While the skin feels cool, it stays pink. Assessing for Hyperthermia: In the early stages of hyperthermia, the person may feel weak and lethargic, complain of headache, nausea, and a loss of appetite. -The skin is usually warm but dry as the sweating response is absent, especially if dehydrated. -In later stages, they become dizzy, dyspnic, tachycardic, have vomiting, diarrhea, muscle cramps, chest pain, mental impairment, and a wide pulse pressure. Assessing Older Adult's Febrile Response to Illness: Nurses need to assess for subtle changes in baseline temperatures and also assess for functional and mental changes.

Nursing Interventions to Promote Healthy Thermoregulation:

Addressing Risk Factors: Maintaining an environmental temperature around 75 degrees is the single most important intervention to prevent thermal imbalance. Humidity is most comfortable between 40-50% but is acceptable between 20-70%. Using humidifiers when it is dry and using fans or AC when it is warm can keep humidity comfortable. -Financial assistance is available for heating and cooling, such as the Low Income Home Energy Assistance Program. Promoting Healthy Thermoregulation: -Keep the temperature at 75 if possible, at 70 for a minimum. In cool environments, proper covering with clothes and blankets is needed. Especially cover the hands, feet, and head since there are a heavier concentration of nerve endings that are sensitive to heat loss. If electric blankets are used, proper safety needs to be taken. Space heaters can warm a small area but can be a fire hazard. -Wear close-knit, but not tight clothing and layers. Wear a hat and gloves outside and a night cap and socks to bed. Extra clothing may be needed in the morning when body metabolism is at the lowest. Use flannel sheets. -Just as important is adequate nutrition and hydration. Fluid intake is even more important during heat waves. Keep the temperature below 85 degrees. - To cool off without AC, use fans to circulate the air, wear loose-fitting, lightweight, light colored cotton clothing. -Wear a hat or use an umbrella when outside. Schedule activities for the cooler hours of morning or evening, not mid-day. -Spend time in air-conditioned public settings, such as libraries or shopping malls. -Avoid heavy meals and strenuous activity during a heat wave.

Risk factors that effect SLEEP Effects of Bioactive Substances:

Adverse effects of medication, caffeine, alcohol, and nicotine can all interfere with sleep. -Caffeine is a stimulant that can keep a person up at night in turn causing daytime sleepiness causing a person to "need" more caffeine. -Higher doses of nicotine can be a stimulant and affect respiration. -Alcohol can make a person drowsy initially, but it decreases REM sleep and increases the number of nighttime awakenings. There is less total sleep time causing more daytime sleepiness. Long-term alcohol use can lead to alcohol-related insomnia for years after stopping drinking. -Hypnotics, and CNS depressants can exacerbate sleep problems, such as obstructive sleep apnea. A tolerance can develop if hypnotics are used regularly (more than a few nights in a row), especially when the dose needs to be increased. Benzos should be avoided in older adults, yet restoril (temazepam) is used frequently. Nonbenzodiazipines are safer and effective, such as lunesta and ambien. OTCs such as benadryl, should also be avoided due to the side effects.

AGE-RELATED CHANGES THAT AFFECT VISION

Affect all the structures involved in visual function; however, in the absence of disease processes, these gradual changes have only a subtle impact on the daily activities of the older person -The cornea becomes opaque and yellow, interfering with the passage of light to the retina -Accumulation of lipid deposits;can cause an increased scattering of light rays and have a blurring effect on vision -Curvature of the cornea influences the refractive ability - Appearance; drooping of the eyelid. Enophthalmos is the appearance of sunken eyes. This can occur in old age from a loss of orbital fat, the development of wrinkles, a decreased elasticity of the eyelid muscles, and an accumulation of dark pigment around the eyes. Relaxation of the lower eyelid muscles can cause ectropion and entropion. In ectropion, the lower eyelid falls away from the conjunctiva, blocking the flow of tears and causing dry eyes In entropion, the lower eyelid becomes inverted and the eyelash rub on the cornea, irritating it, and can cause infection. Arcus senilis is the development of a yellow or gray-white ring between the iris and the sclera from the accumulation of lipids in the cornea. It is associated with diabetes, HTN, hypercholesterolemia, cigarette smoking, and coronary heart disease. -The lens consists of concentric and avascular layers of clear, crystalline protein. Because the lens has no blood supply, it depends on the aqueous humor for metabolic and support functions The lens gradually becomes stiffer, denser, and more opaque. These age-related changes decrease responsiveness of the lens and increase the diffusion of light rays, resulting in fewer rays reaching the retina. the most detrimental effect occurs with the shorter blue and violet wavelengths -Iris is a pigmented sphincter muscle that dilates and contracts to control pupillary size and regulate the amount of light reaching the retina With increasing age, the iris becomes less flexible and the pupil becomes smaller. These changes interfere with the ability to respond to low levels of light and reduce the amount of light that reaches the retina. -The ciliary body is a mass of muscles, connective tissue, and blood vessels surrounding the lens. These muscles regulate the passage of light rays through the lens by changing the shape of the lens. Primary functions of the ciliary body are production of aqueous fluid and control of the ability to focus Muscle cells are replaced with connective tissue, and the ciliary body gradually becomes smaller, stiffer, and less functional. With advanced age, diminished secretion of aqueous humor interferes with the nourishment and cleansing of the lens and cornea -The vitreous is a clear, gelatinous mass that forms the inner substance and maintains the spherical shape of the eye. With increasing age, the gelatinous substance shrinks, causing a proportionate increase in the liquid portion. Because of these changes, the vitreous body pulls away from the retina, resulting in symptoms such as floaters, blurred vision, distorted images, or light flashes -Cone cells diminishes with increasing age, the loss is primarily in the periphery rather than the fovea, and the effects are minimal. The number of rod cells also declines, but the remaining rods increase in size and maintain their ability to capture light. Additional age-related changes in retinal structures include accumulation of lipofuscin, and thinning and sclerosis of the blood vessels and pigment epithelium. -slower processing of visual information

Functional Consequences Associated with Thermoregulation in Older Adults:

Altered Response to Cold: Most older adults are less aware when their body temp lowers and therefore do not compensate by increasing the heat or adding more clothes or covers. This can cause an accidental hypothermia, can progress to cause mental status changes and even death. The age-related diminished ability of the kidney to conserve water and the common occurrence of inadequate fluid intake in older adults exacerbate the effects of hypothermia Altered Response to Heat: Heat exhaustion and heat stroke occurs from fluid depletion or sodium depletion (or both) causing the inability to produce sweat. This is worsened with a decreased thirst sensation. It can lead to respiratory depression and death. Altered Thermoregulatory Response to Illness: Changes in the hypothalamus decrease an older adults febrile response to illness and infection. Older adults also can have a lowered baseline temperature, so an elevated temperature could be considered within normal limits. This can cause infections to be undetected until mental status changes occur. Altered Perception of Environmental Temperatures: When older adults can not accurately gauge environmental temperatures, this is due to an underlying condition, such as dementia, thyroid disorders, or cardiovascular insufficiency, it is not due to age-related changes. Psychosocial Consequences of Altered Thermoregulation: Thermoregulation can cause cognitive changes. Hypo and hyperthermia, untreated, leads to impaired cognition. Just as untreated infections will progress to functional decline included impaired cognition.

Nursing Assessment: SEXUALITY/SEXUAL FUNCTION

An assessment of sexual function should be included when assessing quality of life issues affecting day-to-day functioning, but is not typically done on a routine basis. Whether it is the asexual senior stereotype of the private nature of the topic, sexual function is often overlooked. Self-Assessment of Attitudes About Sexual Function and Aging: Nurses are often uncomfortable discussing sex especially with an older adult who is not in a traditional marriage relationship. Nurses need to examine their own attitudes toward sexual function of older adults to increase their comfort level, their openness to and sensitivity about sexual wellness issues. Assessment of cultural influences -direct eye contact, especially between a man and woman, is interpreted as an expression of intimacy -taboo for a man to be alone with a woman other than his wife. -Touching another person (particularly of the opposite sex) is considered taboo -heterosexual men and women commonly hold hands with one another -Not all cultures value sexual equality between a man and a woman -Homosexuality is accepted in some cultures and considered taboo in others -taboo for postmenopausal women to have their breasts or vagina examined, even by a health care provider -Menopausal manifestations may vary in different cultural groups (e.g., Japanese women may not experience hot flashes). Assessing Sexual Function: The goals of assessing sexual function include providing an opportunity for the older adults to address any issues and identifying risk factors that can interfere with sexual function and quality of life. It should include gynecologic information for females and genitourinary information for males. These can be incorporated into a full assessment and open the door to a discussion on sexual function. The PLISSIT model can be used for routine nursing assessments. -Obtain Permission from the client to initiate a sexual discussion -Provide Limited Information about sexual function -Giving Specific Suggestions for the individual to proceed with sexual relations -Providing Intensive Therapy surrounding the issues of sexuality for the client

Nursing Assessment of Digestion and Nutrition 1. Interview should include: ? 2. Cues to nutrition and digestion? 3. Physical assessment data? 4. Which lab values would be elevated if a patient is dehydrated? (6) 5. Assessment tools we can use? (4)

Assessment should identify: -Effects of age-related changes on digestion, nutrition, and eating patterns -Risk factors that interfere with optimal nutrition -Cultural factors that influence eating patterns -Nutritional status and usual eating patterns -Negative functional consequences of altered digestion or inadequate nutrition 1. Interviewing about Digestion and Nutrition: Inquire about: -Usual eating patterns and nutrient intake -Health behaviors associated with oral care -Age-related changes and risk factors that affect nutritional needs or digestive processes -Environmental or social support factors that affect procurement, preparation, and enjoyment of food -Symptoms of gastrointestinal dysfunction Nurses can assess the adequacy of nutrient intake by asking older adults to describe foods and beverages during an average day/24 hour period 2. Observing Cues to Digestion and Nutrition: Nurses can observe older adults during meals and assess chewing and swallowing. This is especially important in older adults at risk for dysphagia. 3. Physical Assessment: -Height, weight, and BMI are important for nutritional status. -Weight loss or gain is described as a percentage since 5 lbs might not be significant if the person weighs 300 lbs, but if they are 75 lbs, it is. -An unintentional weight loss of more than 5% in 1 month or 10% in 6 months is a significant indicator of poor nutrition. -General assessment of weight, subcutaneous fat, size and strength of muscles, skin, pulse and BP, edema, hair, eyes, mood, walking and balance can give indicators of malnutrition. -Thorough assessment of the oral cavity, abdomen, and rectum can also indicate a nutritional deficiency. -Tongue dryness indicates poor hydration. -Skin turgor should be done on the forehead or anterior chest in older adults. -Dehydration presents with orthostatic hypotension, oliguria or anuria, changes in mental status, dry tongue and mucous membranes and a sudden loss in body weight. 4. Lab values: -The specific gravity of urine increases above 1.030 and urine is concentrated with dehydration. -Sodium, H&H, creatinine, osmolality, and BUN are all typically elevated with dehydration also. -For nutrition, labs that can indicate a nutritional deficiency include: ferritin, folate, or vitamin B12 anemia, lymphocytopenia, albumin of less than 3.5 g/dL, cholesterol of less than 160 mg/dL, and total iron binding capacity of less than 250 mcg/dL. 5. Assessment Tools: -Acute stroke dysphagia screen: is for pts admitted to the hospital to determine if they need a speech therapy referral or can be placed on a general diet. There are 4 screening questions and a bedside swallow test with water. -Mini Nutritional Assessment: 6 screening questions and 12 assessment questions that takes about 15 minutes to complete. -There is also a short form with 6 questions that can be answered in 5 minutes as a first-step screening for poor nutrition. -Brief Oral Health Status Exam: evaluates nursing home residents with and without cognitive impairment, but is validated for community-dwelling and hospitalized patients as well. The BOHSE assessment begins with observation and palpation for enlarged cervical lymph nodes and includes a complete oral cavity evaluation. Using a pen light, tongue depressor, and gauze, the conditions of the oral cavity, surrounding tissues, and natural/artificial teeth are examined and categorically graded from 0 (normal) to 2 (significantly problematic). -Nutrition Screening Initiative: questions to self-administer to determine if there is no nutritional risk, moderate risk, or high risk.

Assessing Behavioral Cues and Environmental Influences on Incontinence

Behavioral Cues -Does the older adult use disposable or washable pads or products? -Is there an odor of urine on clothing, floor coverings, or furniture (particularly couches and stuffed chairs)? -Has the older adult withdrawn from social activities, particularly those held away from home? Environmental Influences -Where are the bathroom facilities located in relation to the older adult's usual daytime and nighttime activities? -Does the person have to go up or down stairs to use the toilet at night or during the day? -Are there any grab bars or other aids in, near, or on the way to the bathroom? ♦Is lighting adequate and the pathway uncluttered for safety? -Would the person benefit from using an elevated toilet seat? -Does the person use a urinal or other aid to cut down on the number of trips to the bathroom? -How many people share the same bathroom facilities? -Is privacy ensured?

RISK FACTORS THAT AFFECT DIGESTION AND NUTRITION Medication Effects What types of medications affect the intestinal flora?

Broad-spectrum antibiotics can alter intestinal flora and impair nutrient synthesis. -Medications and vitamins that are similar in chemical structure may compete at sites of action, thus altering their excretion pattern. -Some medications bind to particular ions and form compounds that cannot be absorbed - Tetracycline can bind to iron and calcium). -Diuretics can interfere with the transport of water, sodium, glucose, and amino acid.

1. Age-related changes are likely to interfere with an older person's ability to respond to cold temperatures: 2. Response to Hot Temperatures? 3. Normal Body Temperature and Febrile Response to Illness?

COLD -Inefficient vasoconstriction -Decreased cardiac output -Decreased muscle mass -Diminished peripheral circulation -Decreased subcutaneous tissue -Delayed and diminished shivering HEAT -Higher threshold for the onset of sweating -Diminished response when sweating occurs -Dulled sensation of warm environments -Renal and cardiovascular changes -Diminished thirst sensation, which can lead to inadequate fluid intake ILLNESS Studies indicate normal core body temperature in older adults begins to decrease An elevated temperature, or fever, is the body's protective response to pathologic conditions, such as cancer, infection, dehydration, or connective tissue disease. This protective response is blunted in older adults because of age-related changes involving thermoregulation and the immune system

Cataracts: s/s Tx?

Cataracts are caused by the progression of age-related changes in the lens that begin in middle adulthood and eventually can progress to total opacification. -As cataracts develop, the normally transparent lens becomes cloudy, transmission of light to the retina is diminished, and vision is impaired. - In addition to being caused by age-related changes, risk factors include systemic disease, medications, and environmental factors. -Cataracts affect reading and night driving -They cause dimmed or blurred vision, distorted double vision -frequent changes in vision prescription -increased sensitivity to glare -more light needed to read -a sensation that there is a film on the eye -halos around bright lights -diminished color perception Cataracts can be treated with glasses, medication, or surgery as it progresses.

Age related changes that affect Urinary Wellness Changes in the Kidney? Changes in the Bladder and Urinary Tract? Additional changes that affect urinary function?

Changes in the kidneys: The kidneys filter and remove chemical wastes from the blood and excreted through the urine.How well the kidneys are working is measured by GFR, which calculates the number of nephrons working properly and the amount and rate of renal blood flow. - Decreased blood flow - Number of functioning nephrons begins to decline and continues gradually throughout life. -It is more difficult for the kidneys to conserve salt with a salt restriction which can cause hyponatremia and other electrolyte imbalances. Changes is the Bladder and Urinary Tract: -In younger adults, the bladder expands 350-450 mL before a person feels full. With age, the bladder hypertrophies and does not stretch as well, limiting the amount of urine it can hold to about 200-300 mL. -Age-related changes involves the loss of smooth muscle in the urethra and the relaxation of the pelvic floor muscles which reduces the urethral resistance and decreases the tone of the sphincters. Changes in Control Mechanisms: Changes in the nervous system can also affect urinary function. Motor impulses in the spine control urination, centers in the brain detect bladder fullness, for preventing voiding when necessary, and for stimulating bladder contraction for complete emptying.' (SNS decreases the need to void) -An age-related change to the cerebral cortex may decrease the sensation of bladder fullness and the ability to completely empty the bladder. Also, the sensation of bladder fullness occurs when the bladder is fuller than in younger adults so there is less time between the urge to void and the actual need to empty the bladder, which can trigger incontinence. -Hormonal changes in postmenopausal women can cause a loss of tone, strength, and collagen and can decrease the urethral closure pressure which predisposes older women to urinary leakage. -Diminished thirst in older adults can affect homeostasis and urinary function as well and increase the risk for dehydration.

Age related Changes: HEARING External ear Middle ear Inner ear

External Ear Age-related processes that interfere with the normal processes of expelling cerumen include an increased concentration of keratin, growth of longer and thicker hair thinning and drying of the skin lining the canal cerumen is drier and more difficult to expel Middle Ear primary functions are to transmit sound energy and protect the middle and inner ear. -Thinner and stiffer eardrum (collagenous tissue replaces the elastic tissue) -Age-related calcification of the ossicles can interfere with the transfer of sound vibrations from the tympanic membrane to the oval window Inner Ear Age-related changes of the inner ear include loss of sensory hair cells reduction of blood supply diminution of endolymph production decreased basilar membrane flexibility degeneration of spiral ganglion cell loss of neurons in the cochlear nuclei

Educating Older Adults about Medications and Sleep:

For many years, benzodiazepines were widely used to induce sleep. Do to the extensive adverse effects in older adults, such as falls, mental changes, daytime sleepiness, tolerance, dependence, decreased REM sleep, and abuse potential, they are no longer recommended. Ambien and Sonata are recommended for use in older adults but are for short-term use only. Lunesta is the only drug approved for long-term use. However, when I worked for Nephrology Associates, it was only covered by insurance in about 1 out of 10 (non-Medicare) patients. Educational points: -Older adults are more susceptible to adverse effects of sleeping medications -OTC sleeping meds usually include benadryl which can cause constipation, confusion, and blurred vision (risk for falls) -Sleeper usually interfere with daytime functioning and the quality of nighttime sleep -A tolerance to hypnotics takes between a week and a month to occur with regular use -can interfere with the dream stage of sleep and cause a rebound effect, causing nightmares and excessive dreaming after they are discontinued -Alcohol can cause nightmares and awakenings during the night -Medications that can interfere with sleep include steroids, diuretics, anticonvulsants, decongestants, and thyroid hormones -Combining medications with sleeping pills can be harmful or even fatal =(

Age related Changes: HEARING 1. Auditory Nervous System: -Function? -A-RC?

Functions of the auditory nervous system include localizing sound direction, fine-tuning auditory stimuli, and transferring information from the primary auditory cortex to the auditory association area. -Degenerative changes in the inner ear -Narrowing of the auditory meatus from bone apposition -Diminished blood supply -Central nervous system changes.

Glaucoma: Types tx interventions

Glaucoma is from an increased pressure of aqueous humor pushing on the optic nerve and damaging the ganglion cells causing a loss of peripheral vision. If untreated, it can progress to blindness. Chronic (open-angle) glaucoma is when the drainage canals for the aqueous humor become clogged. This accounts for 90% of glaucoma. It causes increased intraocular pressure, poor vision in dim lighting, and increased sensitivity to glare. It progresses to poor peripheral vision, a fixed and dilated pupil, halos around lights, and frequent changes in eye Rx. It progresses slowly and can be managed with medications. Surgery is an option if needed. Normal-tension glaucoma occurs in older adults. The intraocular pressure is normal, but the optic nerve is damaged and the visual field is narrowed. This is managed with the same medications and surgery as chronic glaucoma. Acute (closed-angle) glaucoma is caused by a sudden, complete blockage of the flow of aqueous humor. It has an abrupt onset and is a medical emergency. There is an increase in intraocular pressure, severe eye pain, clouded or blurred vision, dilated pupil, and nausea and vomiting. Medication can stabilize it, but usually surgery is required. EDU/TX focuses on the importance of adhering to ongoing medication routines and regularly being evaluated by their eye care practitioner. If older adults with glaucoma are admitted for institutional care, nurses need to ensure that prescribed eye drops are administered as ordered.

Nursing Assessment: SLEEP

Goals of nursing assessment are to: (1) identify health-promoting behaviors that can be encouraged (2) to identify conditions that interfere with sleep so these can be addressed. -ask about quality/adequacy of sleep - ask about nighttime routine/sleeping pattern - discuss health promotion activities Two easy-to-use and readily available tools that have been tested for validity and reliability are the: -Pittsburgh Sleep Quality Index (PSQI) -Epworth Sleepiness Scale (ESS). The PSQI assesses sleep quality and patterns over the past month, and the ESS focuses on daytime sleepiness over the past week.

Nursing Interventions: VISION

Health Promotion for Visual Wellness: This focuses on maintaining vision, compensating for any visual deficits, and identifying and treating conditions early. -Promote broad brimmed hats -UV-B absorbing sunglasses -diets high in lutein -annual eye exams -evaluation of changes in vision, smoking cessation -good control of diabetes and HTN Educate on the differences between Ophthalmologists, Optometrists, and Opticians, health insurance coverage, eye diseases, common vision problems, age-related changes, and vision aids. Comfort Measures for Dry Eyes: -OTC artificial tears or lubricants usually relieve symptoms. -Applying a cold compress or wearing wrap around sunglasses can help prevent the evaporation of tears. - Using a humidifier, avoiding smoke and hair spray can add comfort as well. Environmental Modifications: Environmental modifications are intended to improve safety and decrease falls and accidents. -Proper nonglare lighting, such as broad-spectrum fluorescent lights, is the most effective, cheapest, and easiest intervention. -Poor color contrast can make it difficult to differentiate items. -Placing a dot of nail polish on the thermostat can help determine where to adjust the temperature to. -Using a clear plastic shower curtain will let more light in. -Use nightlights or flashlights when getting up at night -Illuminate light switches -Use illuminating or magnifying mirrors -Have light colored and dark colored cutting boards to contrast light or dark meat and veggies when cutting -Use pens with black ink instead of blue to create a stronger contrast Low-Vision Aids: -Low-vision aids improve focus, contrast, magnification, or illumination. -Magnifying reader glasses are available without a prescription -Copy machines usually can be set to copy images larger than the original for handouts -Using a magnifying glass: comes in a handheld, stand, or mount Maintaining and Improving the Quality of Life: Using reading glass and having appropriate lighting can enable older adults to be able to read books, magazines, or newspaper which can satisfy social interactions and be intellectually stimulating. Include foods high in lutein, such as fruits, corn, spinach, green leafy vegetables, and egg yolks. May be effective in preventing cataracts and AMD

Risk Factors for hearing loss What types of things is hearing loss associated with? 1. 2. 3. 4. 5. 6.

Hearing loss associated with: -lifestyle -heredity -environmental factors -medications -impacted cerumem -disease conditions Lifestyle and Environmental Factors: ---Prolonged or intermittent exposure to noise can cause hearing loss. Noise-induced hearing loss is the most important preventable cause of heading loss in the US. -Occupations associated with NIHL are farmers, musicians, truck drivers, armed service members, and aviation workers. -The use of headphones to play music is also a risk. Hunting or target shooting Riding all-terrain vehicles or motorcycles. Operating power tools (e.g., chain saws, leaf blowers, drills). -Exposure to toxic chemicals can be another cause of hearing loss. Research is looking the affects of metals, solvents, asphyxiates, and pesticides or herbicides. Impacted Cerumen: Impacted cerumen is common in older adults and causes hearing loss. It can be from age-related changes that we already discussed, or it could be impacted from using a hearing aid. Impacted cerumen can also cause pain, infection, tinnitus, dizziness, or chronic coughing (from stimulating the vagus nerve). Genetic predisposition -impacted cerumen -male gender -increased age Ototoxic Medications: -Aminoglycosides (e.g., gentamicin, neomycin) -Aspirin and other salicylates -Cisplatin and other chemotherapeutic agents -Hydroxychloroquine -Loop diuretics (e.g., bumetanide, furosemide) ***increase the risk for medication-related ototoxicity, such as renal failure, dehydration, and potentiation between two ototoxic medications, such as furosemide and aminoglycoside antibiotic Medical conditions -Diabetes -Hypertension -Cardiovascular disease/ lipid disorders -Ménière disease -meningitis -hypothyroidism -head injury -high fevers -Paget disease, -renal failure -viral infections -Otosclerosis: hereditary disease. It is a hardening that causes the footplate of the stapes to become fixed in the oval window, impeding the transmission of sound and causing progressive deafness that begins typically in the 20's-40's

-What are the 3 types of hearing loss? Describe. -What type of hearing loss is associated with presbycusis and ototoxicity?

Hearing loss is categorized by the type of impairment. Conductive hearing loss is from an abnormality of the external or middle ear that impair sound conduction. This is a mechanical problem. Typically only a partial loss; sound is amplified enough, the sound can reach the inner ear. Otosclerosis is also a conductive hearing loss. Sensorineural hearing loss is from an abnormality of the inner ear that interferes with sensory and neural structures that is often age-related or noise induced. This is a perceptive loss and amplitude does not improve hearing. Could be pathology of the inner ear, CN VIII, or the auditory areas of the cerebral cortex. Presbycusis and ototoxicity are sensorineural hearing loss. Mixed hearing loss involves both.

Pathological Condition Affecting Sexual Wellness:

Human Immunodeficiency Virus: HIV is becoming more common in older adults. HIV is now considered a chronic disease due to the antiretroviral therapy effectiveness and people are living longer with HIV/AIDS. Risk Factors for HIV: -In older adults, IV drug use and sexual contact between gay men are the primary risk factors for HIV. But, more than half of women infected are from heterosexual transmissions and only about 15% from IV drug use. Only 15% of the older adult population reported using condoms and less than 10% were tested for HIV when reporting at least one symptom. -In older women with vaginal dryness, there is an increased risk for trauma during intercourse, which increases the chance of transmission.

Dysphagia as a Risk for Aspiration Recommendations for Nursing Interventions (13 different)

Includes: -speech-language pathologists -dietary professionals -primary care practitioners -use swallowing assessment tool -water-swallowing test -muscle-strengthening exercises -postural adjustments (e.g., chin-down or chin-tuck maneuver) or swallow maneuvers -diet modification (e.g., altered viscosity, thickened liquids) -resting for 30 minutes before eating sitting upright, allowing at least 30 minutes for eating or assisted feeding -alternating small amounts of solid and liquid foods -minimizing distractions -Good oral care is imperative for all patients with dysphagia because it is associated with a lower incidence of pneumonia.

Internal conditions that affect Thermoregulation include: External influences on thermoregulation include:

Internal: -Metabolic rate -Pathologic processes -Muscle activity -Peripheral blood flow -Amount of subcutaneous fat -Central nervous system function, the temperature of the blood flowing through the hypothalamus -Effects of medications and other bioactive substances. External: -environmental temperature -humidity level -airflow -type and amount of clothing and covering use

Interventions for Cerumen Impaction

Interventions for Cerumen Impaction -The goal of clearing the cerumen is to alleviate symptoms or improve hearing; this does not necessarily involve the removal of all cerumen. -Impacted cerumen is removed cautiously by qualified professionals by a variety of methods, including irrigation, cerumenolytic agents, and manually with a specialized instrument. Instillation of cerumenolytic agents 15 minutes or for several days prior to the removal improves the success of the treatment. -Ear irrigation should not be performed on patients with a history of ear surgery or those who have any abnormality of the ear canal or a nonintact tympanic membrane; it should be used cautiously in patients with diabetes. -Patients may be taught to self-irrigate with a bulb syringe; however, jet irrigators should not be used for self-care. Interventions for preventing recurrence include irrigation with bulb syringe and regular use of cerumenolytic agents or alcohol or hydrogen peroxide drops.

Interviewing about hearing changes: What types of questions would we ask?

Interviewing about hearing changes: Gather information about: -Present and past risk factors: did they have a career with environmental noise? Or do they live by an airport? How do they clean their ears? What medications do they take? -The person's awareness and acknowledgement of a hearing loss: Have they noticed they have to turn the volume higher on the TV or it's harder to understand people or use the telephone? Or can you tell they cannot hear you well but they think they can hear well. -How does their hearing loss affect them? -And, their attitudes that might affect health promotion

AGE-RELATED CHANGES THAT AFFECT DIGESTION AND EATING PATTERNS ((What is listed below is the FUNCTION of these organs---a little reminder)) Age related changes of the following organs? Liver: liver assists digestion by producing and secreting bile, which is essential for utilizing fats. It also plays an important role in metabolizing and storing medications and nutrients Pancreas: secretion of enzymes essential for metabolizing glucose, neutralizing acids in the chyme, and breaking down fats, proteins, and carbohydrates Gallbladder: Secretes Bile

Liver becomes smaller and more fibrous blood flow to the liver decreases by approximately one-third ***Despite any age-related or pathologic changes, the liver has an enormous regenerative and reserve capacity, which allows it to compensate for such changes without significantly affecting digestive function. Pancreas: Degenerative age-related changes in the pancreas increase the susceptibility of older adults to the development of type 2 diabetes Gallbladder: Age-related changes that affect the gallbladder and biliary tract include: -diminished bile acid synthesis -widening of the common bile duct -increased secretion of cholecystokinin, a peptide hormone that contracts the gallbladder and relaxes the biliary sphincter. These age-related changes can increase the susceptibility of older adults to the development of cholelithiasis (gallstones)

Teaching about Management of Sleep Disorders:

Nurses often see patients sleep more than any other health care provider and should be assessing sleep and referring patients for a sleep evaluation. If a person has obstructive sleep apnea, the nurse needs to teach about interventions to manage it. This can decrease daytime sleepiness, improve cognitive function, and decrease nocturia. The best treatment is with a CPAP, Continuous positive airway pressure. -With CPAP, patients wear a mask over their nose and/or mouth. An air blower forces air through the nose and/or mouth. -The air pressure is adjusted so that it is just enough to prevent the upper airway tissues from collapsing during sleep. The pressure is constant and continuous. -CPAP prevents airway closure while it is being used, but apnea episodes return when CPAP is stopped or it is used improperly. -Other styles and types of positive airway pressure devices are available for people who have difficulty tolerating CPAP. Mandibular advancement devices -- For patients with mild sleep apnea, dental appliances or oral mandibular advancement devices that prevent the tongue from blocking the throat and/or advance the lower jaw forward can be made. -These devices help keep the airway open during sleep. - A sleep specialist and prosthodontist -- a person with expertise in these types of oral appliances -- should jointly determine if this treatment is best for you. Surgery -- These procedures are typically performed after sleep apnea has failed to respond to conservative measures and a trial of CPAP. Types of surgery include: Somnoplasty -- a minimally invasive procedure that uses radiofrequency energy to tighten the soft palate at the back of the throat. uvulopalatopharyngoplasty -- a procedure that removes soft tissue in the back of the throat and palate, increasing the width of the airway at the throat opening. Mandibular/maxillary advancement surgery -- surgically moving the jaw bone and face bones forward to make more room in the back of the throat -- an intricate procedure that is reserved for patients with severe sleep apnea and head-face abnormalities. Nasal surgery -- correction of nasal obstructions, such as a deviated septum.

Nursing Interventions: SLEEP

Nursing Interventions for Sleep Wellness: -Health education -Environmental modifications -Comfort and relaxation strategies Self-Care Actions to Promote Healthy Sleep: -Moderate physical activity before late afternoon and avoiding vigorous activity in the evening. -Establishing a bedtime ritual and following it nightly. If the bedtime is changed or you don't sleep well, try to get up at the usual time if possible. -Taking a warm, relaxing bath in the afternoon or evening. -Avoiding caffeine and stimulants after 1 pm, such as tea, cocoa, coffee, chocolate, sugar, and certain OTC cold and pain relievers [Dayquil]). -Pre-bedtime foods that promote sleep are warm milk, chamomile tea, and a light snack of complex carbs -Relaxation with imagery, meditation, deep breathing, soothing music, massage, rocking in a chair, and nonstimutaing reading or TV. -Adequate intake of zinc, Ca++, magnesium, manganese, vitamin C, and vitamin B complex -Avoiding alcohol before bedtime, and when used, only in small amounts, to prevent early morning awakening -Avoiding nicotine, which is a stimulant, in the evening Do not use the bed for activities other than sleep (and sex) such as reading or watching TV -If you awaken during the night, get out of bed for 30 minutes and read (or something nonstimulating) in another room Complementary and Alternative Practices: - Bright light therapy (especially with seasonal affective disorder and dementia) -Bioactive substances (melatonin, aromatherapy, herbal products, or homeotherapy remedies), -Body-mind modalities (yoga, imagery, meditation, tai chi, massage, acupressure, soothing music) can all improve sleep. Improving Sleep for Older Adults in Institutional Settings: -Including assistance with personal hygiene -Adherence to the usual bedtime -Providing a 5 minute head-to-toe massage -Straightening the bed linens -Providing an appropriate bedtime snack -Limiting bedside conversation -Darkening the room -Another important intervention is managing pain and anxiety, especially in nonverbal older adults with dementia or depression where nonverbal cues need to be assessed. -An analgesic taken 30 minutes before bed can help sleep. Modifying the Environment to Promote Sleep: -Closing the bedroom door or darkening the room -limiting/eliminating noise or using earplugs or white noise -promoting bedtime routines -comfortable room temperatures can promote sleep.

Nutritional deficiencies increase the risk for ...

Nutritional deficiencies—which increase the risk for: -frailty -poor functioning -pathologic conditions—occur commonly in older adults

What behaviors could indicate hearing loss?

Observing Behavioral Cues: -Inappropriate or no response to questions, especially in the absence of opportunities for lip reading -Inability to follow verbal directions without cues -Short attention span, easy distractibility -Frequent requests for repetition or clarification of verbal communication Intense observation of the speaker -Mouthing of words spoken by the speaker -Turning of one ear toward the speaker -Unusual physical proximity to the speaker -Lack of response to loud environmental noises -Speech that is too loud or inarticulate -Abnormal voice characteristics, such as monotony -Misperception that others are talking about him or her

Response to Cold Temperatures Physiologic mechanisms that are protective in response to cold environments include..? Voluntary protective actions against the cold?

Physiologic mechanisms that are protective in response to cold environments include: -shivering -muscle contraction -increased heart rate -peripheral vasoconstriction -dilation of the blood vessels in the muscles -insulation of deeper tissues by subcutaneous fat -release of thyroxine and corticosteroid by the pituitary gland. Voluntary protective actions that people commonly initiate in cold temperatures include: -seeking shelter -ingesting warm fluids -wearing warm clothing or covering - increasing activity to stimulate circulation

RISK FACTORS THAT AFFECT VISUAL WELLNESS

Poor nutrition, cigarette smoking, and exposure to sunlight increase the risk for the development of eye diseases. -Long-term exposure to sunlight exacerbates the effects of age-related changes to increase the risk for eye diseases. Warmer environmental temperatures are associated with an earlier age of onset for presbyopia( difficulty focusing on objects in your near vision) and cataracts. Environmental conditions, such as wind, sunlight, low humidity, and secondhand smoke, can cause dry eyes. Environmental conditions, such as lighting and color contrast, affect visual function in many ways -The following medications are associated with potential adverse effects on vision: nonsteroidal anti-inflammatory agents (e.g., aspirin), anticholinergics, phenothiazines, amiodarone, sildenafil, alpha blockers (e.g., doxazosin mesylate), and oral or inhaled corticosteroids. -Medications that can cause or contribute to dry eyes include estrogen, diuretics, antihistamines, anticholinergics, phenothiazines, beta blockers, and antiparkinson agents. -Systemic anticoagulants can precipitate intraocular hemorrhage in people with pre-existing macular degeneration

Presbycusis

Presbycusis is the most common type of Sensorineural Hearing Loss caused by the natural aging of the auditory system. It occurs gradually and initially affects the ability to hear higher pitched (higher frequency) sounds.

Presbyphagia

Presbyphagia refers to characteristic changes in the swallowing mechanism of otherwise healthy older adults.

Interventions for Hearing Wellness: How can we promote wellness? Preventing/alleviating impacted cerumen? Compensations for those with hearing deficits? (devices)

Promoting Hearing Wellness for All Older Adults: -Nurses can teach the importance of having a hearing screening done -To prevent further hearing loss, nurses can educate to limit environmental noise and encourage smoking cessation. -If hearing loss is present, a nurse can review medications and medical diagnoses and have the patient's physician investigate further if anything is ototoxic. These medications should be avoided whenever possible in older adults with hearing loss. If the patient does not have hearing loss, but risk factors are present, an alternative is still suggested. -In addition, when hearing loss is present, an older adult should get a referral to an ENT or audiologist. Preventing and Alleviating Impacted Cerumen: -Ceruminolytics: OTC eardrops are available to help soften earwax. Docusate sodium, the constipation medication, comes in a liquid (not the syrup) and is effective, inexpensive, and readily available. The drops only need to be used every 2-4 weeks to keep the wax soft. When the ear canal is already impacted the cerumen needs to be removed. Soften the wax with a ceruminolytic for 15 minutes and then irrigate the canal with body-temp water with an ear syringe with gentle pressure and allow drainage into a basin with the head tilted toward the affected side. If it is not relieved, use the ceruminolytic twice a day for a few days and try again. This is contraindicated if there is pain or swelling, if there was a recent ear infection, or if the person has had a ruptured ear drum. Then refer to an ENT. Compensating for Hearing Deficits: This is consider after a medical evaluation determines if there are any treatable causes for hearing loss and there are not, compensation can be used. -Aural rehab can help people use amplifiers, lip read, do auditory training, and improve speech skills. Nurses can suggest a referrals for aural rehab, discuss it with family and caregivers, and encouraging the use of amplifiers. -Sound amplification can be achieved with hearing aids or assistive listening devices. Hearing aids require a prescription while listening devices can be bought from infomercials. Another option is an electronic device, such as a cochlear implant. Cochlear implants cannot go in an MRI machine! Assistive Listening Devices: Any device that amplifies or replaces sound. A stethoscope is commonly used by health care workers. -Many amplifiers come with headphones which also help block out background noise. -Closed captioning is also considered an assistive listening device. These are usually much cheaper than hearing aids and require less manual dexterity to turn on and can be used with hearing aids. They can amplify radios, TVs, door bells, or phones. - If sound can still not be heard when amplified, flashing lights or vibration can be used for door bells or alarm clocks. Hearing Aids: Hearing aids are battery operated. The can sit in the ear, in the canal, and new, smaller ones that are completely in the canal. They also come in analog or digital versions. Analog are the least expensive, about $400, but can be difficult to use in noisy environments but good for 1:1 conversations. Digital hearing aids are the most expensive, several thousand dollars, but can be programmed by an audiologist so it is specific to the frequencies of hearing lost. Despite the options, only about 20% of people who could benefit from them, wear one. Nurses can help older adults explore the options and find one that is best for their budget and needs. -

Nutrients of Particular Importance to Older Adults (9)

Protein -Protein deficiency is associated with loss of muscle tissue and increased risk for sarcopenia and frailty Current recommended dietary allowance for protein (i.e.,.8 g/kg/day) is the same for all adults, without consideration of increased age Many recent studies indicate that daily protein intake of 1.2 to 1.5 g/kg is safe for older adults and is beneficial in preserving muscle mass. A substantial percentage of older adults do not meet current recommended protein intake Fiber -Dietary fiber is essential for maintaining colonic functioning. -Average intake of dietary fiber is half the recommended levels Folate Important for cognitive function, DNA methylation, and preventing high levels of homocysteine -Some older adults do not meet the RDA, others exceed the upper limit and get too much of synthetic folic acid from fortified foods (e.g., cereals) and supplements -Excess intake of folate can mask vitamin B12 deficiencies, which can cause neurologic deterioration Vitamin D Inadequate Vitamin D intake increases the risk for: - osteoporosis -neurologic conditions - cardiovascular disease -other chronic diseases Inadequate exposure to sunlight Calcium Low intake of calcium affects many systems, including the skeletal, cardiovascular, and neurologic systems Inadequate dietary intake of calcium is common in older adults Magnesium ---Important for maintaining normal blood pressure. Aids in mood improvement Potassium Potassium is considered a "nutrient of public health concern" because of its critical roles in muscle function, cardiac function, and regulation of blood pressure Zinc Zinc deficiency occurs commonly in older adults and leads to anorexia, impaired immune function, delayed wound healing, and smell and taste disturbances Sodium Over-consumption of sodium is considered a "nutrient of public health concern" because of its association with adverse health events, such as hypertension

Risk factors that effect SLEEP Psycho-social

Psychosocial Factors: -Belief and attitudes about sleep can cause a lot of anxiety for some older adults. Some older adults believe that if they wake up during the night, it is from insomnia. Others have very rigid beliefs on the amount of sleep needed and if not met can be thought to be insomnia. -Also, worrying about sleep can impact sleep. Anxiety, dementia, and depression can also disrupt sleep. -Anxiety and dementia can cause falling asleep difficulties, frequent awakenings during the night, and again difficulty returning to sleep. -Dementia also causes an increase in time spent in light sleep stages, very little REM and deep sleep, less total sleep time, disrupted sleep-wake cycles with frequent nighttime arousals and daytime napping. These changes are more severe as dementia worsens. -Depression can also make it take longer to fall asleep, have less deep sleep and more light sleep, awakening more at night and early in the morning, and not feeling rested during the day. -It can be difficult to establish a healthy sleeping pattern for older adults that do not have work, activities, responsibilities, or stimuli throughout the day. Older adults may stay in bed out of lack of motivation, boredom, difficulty concentrating, or wanting to withdraw from stressful situations. -If an older adults spends all of their time in the same room, a lack of space for sleeping and a space for being awake can interfere with sleeping patterns.

Psychosocial consequences of hearing loss?

Psychosocial consequences: §Depression §Social isolation §Declines in cognitive function §Diminished quality of life

Functional Consequences Affecting Sexual Wellness:

Reproductive Ability: Ova production ends within one year of the last menstrual cycle which causes a loss of reproductive ability. If an ova becomes fertilized during the premenopausal years, there is an increased risk of birth defects. In men, reproductive abilities decline with age, but do not stop completely. Response to Sexual Stimuli: There are four phases of physiologic response to sexual stimulation excitement phase plateau phase orgasmic phase resolution phase With age, older adults can maintain their response to sexual stimuli, but it is slower and less intense. Regularly engaging in sexual activity helps older adults respond to sexual stimuli. And changes are due to risk factors, not aging. Sexual Interest & Activity: -While sexual activity declines with age, sexual interest does not. Sexual interests, attitudes, activity, and satisfaction are a continuation of lifelong patterns and remain stable in older adulthood unless risk factors interfere. - As opportunities change, many older adults stated touch and caressing without sexual intercourse was satisfying. Male Sexual Dysfunction: Erectile dysfunction has replaced the term impotence, and has received a lot of attention since the availability of Viagra and similar medications. Other dysfunction includes problems with ejaculation and diminished desire. Female Sexual Dysfunction: Female sexual dysfunction affects sexual desire (including motivation and physical drive), sexual arousal, orgasm, and pain during sex (dyspareunia)

Screening version of the Dizziness Handicap Inventory (DHI-S)

Screening version of the Dizziness Handicap Inventory (DHI-S) It is a 10-item patient self-assessment questionnaire that takes fewer than 5 minutes to complete. You can also use the DHI-S to supplement the Timed Up & Go test in judging a patient's postural control. The higher the score, the greater the need for further evaluation.

Screening version of the Hearing Handicap Inventory for the Elderly (HHIE-S)

Screening version of the Hearing Handicap Inventory for the Elderly (HHIE-S) It is a 10-item patient self-assessment questionnaire that takes fewer than 5 minutes to complete. It was developed for cognitively intact older adults. A score of 10 or greater may benefit from additional hearing evaluation. 0-8 has a 13 % chance of hearing loss 10-24 has a 50% chance of hearing loss 26-40 has a 84% chance of hearing loss

AGE-RELATED CHANGES THAT AFFECT DIGESTION AND EATING PATTERNS Intestinal Tract (2)

Small Intestine: Age-related degenerative changes in the small intestine do not significantly affect digestive functions; however, they may affect immune function and absorption of some nutrients, such as folate, calcium, and vitamins B12 and D. Large Intestine: Age-related changes in the large intestine include reduced secretion of mucus and decreased elasticity of the rectal wall. ------ may predispose the older person to constipation.

Risk Factors that Affect Sexual Function:

Societal Influences: -Many older adults are influenced by Victorian standards, including homosexuality, public displays of affection, and sex with anyone except a marital partner is taboo. (Older gay, lesbian, and bisexuals are even more vulnerable to myths and stereotypes about sexuality and at risk for more loneliness.) -Another societal influence is the Western societies' association with physical attractiveness and sexual attractiveness that are gender-specific and stereotypes. Male sexuality is portrayed as young, muscular, tan men. Female sexuality is portrayed as young, thin, well-endowed women. While this is drastically different from the stereotypical images of older adults, they are often thought of as physically unattractive, therefore sexless. These societal influences lead people to believe that older adults have lost interest or capacity for sexual activity. Older adults can also have these beliefs and make themselves sexless. Or they may have sexual desires but feel embarrassed or abnormal. Attitudes & Behaviors of Families & Caregivers: Caregivers and family members who are close the older adult can negatively impact their sexual function also. Adult children often think of their parents as asexual and can have a hard time thinking dealing with their parents' sexuality. Also, children can discourage an intimate relationship for a parent if they fear it could affect their inheritance. In a nursing home, staff usually ignore the sexual needs of residence and the only acceptable expression is with their spouse privately. Masturbation and sexual activities between two unmarried people is typically not tolerated, even when the older adult is competent. Staff often ask the family members to intervene. If the older adult is not competent, such as with dementia, decision become even more difficult. Limited Opportunities for Sexual Activity: In men, the decline in sexual activity is most often due to health problems. In women, the decline in sexual activity is most often due to the lack of an interested and functioning partner Even with a partner, lack of privacy can also limit the opportunities when an older adult lives with family or in a nursing home. Especially in a nursing home as rooms are often doubles, doors do not lock, and there is only a single bed. Adverse Effects of Medication, Alcohol, & Nicotine: Most studies have focused on men and erectile dysfunction, but medication, alcohol, and nicotine can affect women as well. Sexual adverse effects of medication has a major affect on quality of life and adherence to prescription regimens. In addition to ED, men experience decreased libido, dry, premature, or retrograde ejaculation, the inability to achieve an orgasm, or priapism. Women can experience decreased vaginal lubrication, decreased libido, and the inability to achieve an orgasm. Typically the side effects disappear if the medication is discontinued or possibly with a dose decrease. Alcohol can also interfere with sexual function, since it depresses the CNS, and can interfere with sexual performance. Cigarette smoking has been known to be a cause of ED since the 1980's and it is now known that it can cause sexual dysfunction in both men and women since it interferes with circulation to sexual organs. Cigarette smoking also is associated with an earlier onset of menopause and an increased intensity and frequency of hot flashes.

Nursing Interventions: SEXUALITY

Teaching Older Adults About Sexual Wellness: Nurses should teach about safe sex practices for older adults who are sexual active with anyone other than a long-term monogamous partner. It should include: -Acknowledge that sexual function is part of health promotion -The effects of age-related changes -Risk factors that cause or contribute to problems -Resources available -Protection for STIs Nurses may need to teach other nurses, caregivers, or family members as well. Addressing Risk Factors: When a nurse identifies risk factors in an older adult with sexual dysfunction, they should suggest they seek professional advice. If it is due to medication, alternative doses or medications could be tried. If diseases, such as arthritis are a problem, trying alternate positions or using an analgesic prior could help. After medical problems are addressed, a mental health professional may be a resource. Promoting Sexual Wellness in Long-Term Care Settings: Acute care settings focus on intense medical needs that are more important, at that moment, than sexual needs, but in a long-term care facility, where you build an ongoing relationship with the older adults, and the older adults depend on the caregivers for privacy and personal needs, sexual needs must be a part of the overall care plan. For this to occur, staff education is typically needed about sexuality and aging. Nurses need to ensure privacy for all residents as well. Teaching Women about Interventions: Interventions for a healthy lifestyle, such as regular exercise, relaxation techniques, nutritious food, and a healthy weight, are recommended for all women without controversy. On the other hand, hormone replacement therapy, available either systemically or vaginally, has a lot of controversy. It can treat menopause-related symptoms including hot flashes or night sweats and reduce the risk of vaginal atrophy, osteoporosis and fractures, but comes with many risks as well with the biggest risk an increased risk for cancer. Women who experience hot flashes can wear lightweight clothing, keep the environment cool, and avoid spicy foods and women with vaginal dryness can use water-soluble lubricants or prescription estrogen creams, as well. Teaching Men about Interventions: -Viagra, Levitra, and Cialis are available to treat ED so men are now seeking treatment where as in the past they did not. These drugs are safe and effective in older men not taking nitrates. -Testosterone replacement therapy is available but not typically used due to the increased risk for BPH and prostate cancer. -Herbal remedies, such as yohimbine, are available, but have not been tested for safety or efficacy. -In addition to oral agents, penile prosthesis implants are safe, reliable, and effective and vasoactive drugs can be injected into the base of the penis or given as a transurethral suppository. -Smoking cessation can improve ED, as can pelvic muscle exercises.

Nursing Assessment: VISION

The nursing assessment should identify: -Factors that affect visual wellness -Vision problems -The impact on safety, independence, or quality of life -Opportunities to promote visual wellness -Barriers to implementing interventions Interviewing about vision changes: Ask questions about past and present risk factors, if the person has noticed any vision changes, how those vision changes has affected daily activities or quality of life such as driving, shopping, or meal preparation, and how they feel about interventions. If they have noticed vision changes, when did it begin, was it sudden or progressive, and what causes discomfort, and any history of tripping, falling, or near-falling? Identifying Opportunities for Health Promotion: -Determine the usual eye care practices and determine if that could interfere with wellness. The dates, frequency, and source of eye exams will help you plan interventions to detect eye diseases early. -Whether the person has eye diseases already or not, determine their attitudes about eye disease and eye exams for myths or misunderstandings - include modifiable risk factors, such as cigarette smoking, sun exposure, and use of sunglasses Observing Cues to Visual Function: (Behavioral/environmental) Observe the eyelids, appearance, and ability to perform daily activities. Does the person have glasses and do the wear them? Has their appearance changed? Clothes dirtier or make-up heavier? Do they use their hands to feel for objects while walking? In the home: what kind of lighting is used? Is it sufficient? Is there glare? Is there contrast between the walls and floors? Are nightlights used? Using Standard Vision Tests: These vision tests are not a substitute for an eye exam, but can provide information to plan care. The Snellen eye chart is for far vision acuity The Amsler grid is for age-related macular degeneration The confrontation test is for peripheral vision The Jaeger test is for near vision acuity. Always test one eye at a time while the over is covered and do not have the patient use their hand to cover the other eye.

Functional Consequences: SLEEP

The overall functional consequences of age-related changes in sleep are insufficient, inefficient, and poor quality sleep. Common sleep complaints of older adults include: -Daytime sleepiness -Difficulty falling asleep -Frequent arousal during the night Health Consequences Poor sleep is associated with increased risk for all the following serious health consequences: -stroke -cancer -obesity -diabetes -cardiovascular diseases -cognitive impairments -metabolic syndrome -substance abuse -accidental injuries

Functional Consequences 1. Urinary Incontinence: Risk factors 2. Types of Urinary Incontinence? 3. Transient urinary incontinence

Urinary Incontinence: Age-related changes do not cause incontinence but predispose older adults to it. 1. Risk factors include: -increased age -functional limitations (ADLs) -impaired cognition -obesity -smoking -white race -constipation -vaginal delivery -low vitamin D levels -certain medications and diseases. 2. Types: Stress: involuntary leakage from increased abdominal pressure Urge: involuntary leakage from the inability to hold urine long enough to reach the toilet after the urge is felt Mixed: involuntary leakage from urgency and activities such as coughing, sneezing, or exertion. Overactive bladder: bothersome urgency, with nocturia and day-time frequency, but does not necessarily have incontinence, but are common together. Obesity and diuretics can cause this as well 3. Transient urinary incontinence characterized by recent and sudden onset and is associated with resolvable causes, such as: -delirium -UTIs -medications -constipation -limited mobility -lack of appropriate assistance with toileting

Using Hearing Assessment Tools:

Using Hearing Assessment Tools: -Otoscope to look for cerumen or other factors that could interfere with hearing, such as a ruptured tympanic membrane -Weber: The Weber and Rinne tests have been proven inaccurate and unreliable for general screenings but can be better than nothing at all. For the Weber test, place a vibrating tuning fork on a person's forehead and ask if it is heard louder in one ear or the other. This is assessing air and bone conduction, and if you place it halfway between the ears, it should sound equal in both ears. If it is louder in one ear than the other, hearing loss is possible. -Rinne: cover one ear and test the uncovered ear, one at a time. Place the vibrating tuning fork behind the person's ear and have them say when they can no longer hear it. This is bone conduction hearing. When they say can't hear it anymore, move the tuning fork to in front of the ear and see how much longer they can hear it now. This is air conduction. The normal expectation is AC:BC is 2:1. If the AC is heard for less than twice that of the BC, hearing loss is possible. Brief Hearing Loss Screener: The Brief Hearing Loss Screener is unique in that it considers the risks associated with advancing age, gender and educational level of the individual. Scores can range from 0 to 8. A score of 3 or more points is a positive score indicating a need for further evaluation. The person must be cognitively intact and can respond verbally or in writing to the questions.

Age related Changes: SEXUALITY Women: Men:

WOMAN -Frequency of ovulation diminishes -Menstrual cycles become shorter and irregular. ------- --Menopause is the normal age-related physiologic process that indicates the loss of reproductive ability in women. About 70% of women experience hot flashes, a sudden onset of heat, sweating, and flushing that lasts 1-5 minutes. In most women, they subside after about 5 years, but not for all women -The breasts become more pendulous and have more fat and less mammary tissue -Vaginal dryness from decreased secretions -Decline in endogenous estrogen levels; skin and fat tissue in menopause causing estrogen levels to decline. MEN -Andropause, also called testosterone deficiency, androgen deficiency, or late-onset hypogonadism, is the age-related decline in testosterone in men that starts in the 30's and is even lower in men who smoke. Despite the changes in testosterone and the production and motility of the sperm, some men never lose their reproductive abilities. Others have low libido, erectile dysfunction, decreased viitality, and depressed mood. It can also increase the risk for cardiovascular disease and type 2 diabetes -Loss of muscle tissue and strength -Osteoporotic fracture -Diminished facial, axillary, and pubic hair Mood changes -Sleep disturbances -Fatigue -Hot flashes -Decreased libido -Erectile dysfunction

What should a hearing assessment include?

Your assessment should: -Identify factors that interfere with hearing wellness -Identify any actual hearing deficits -Identify the impact of hearing deficits on safety and quality of life -Identify opportunities to improve hearing wellness -identify barriers to implementing interventions. -Begin with family history and past experience to loud noise. -Ask about a history of diabetes, hypothyroidism, Meniere's disease, or Paget disease. . -Ask if patient has a history of impacted cerumen. -Next, ask patient if they have trouble hearing or understanding conversations. -Ask about tinnitus -If they state they have noticed a hearing loss, inquire further about for how long, one ears or both, progressive or sudden, describe (i.e. high tones or low), background noise make it worse, does it cause trouble with communication, effect social or occupational activities? -Evaluated for or used a hearing aid? What are their attitudes about hearing loss, hearing aids and assistive devices? More than 1/3 of older adults would benefit from a hearing aid, but only 10% use one.

RISK FACTORS THAT AFFECT DIGESTION AND NUTRITION Socioeconomic Influences are associated with lack of ________ and more ________ loss.

associated with lack of dental care and more tooth loss

Digestion and Nutrition AGE-RELATED CHANGES THAT AFFECT DIGESTION AND EATING PATTERNS Conditions that lead to decreased sense of smell/taste?

both these senses decline in older adults because of a combination of age-related changes and risk factors The ability to detect and identify odors is best between the ages of 30 and 40 years, then it gradually declines. Conditions that can lead to impaired olfaction include: -smoking or chewing tobacco -viruses -poor oral health -periodontal disease -nasal sinus disease -trauma -medications (e.g., diuretics and antidepressants)

Nutritional requirements: % daily values Calories ? Protein? Carbs/fiber ? Fat? Water?

cals- less quantity, better QUALITY (d/t decreased activity) Protein- minimum of 1.0-1.6g/kg of body weight (d/t decreased muscle mass) Carbs/fiber- 25-38g/day Fat- no more than 30% of daily caloric intake Water- ESSENTIAL

Vertigo

dizziness

Presbyopia

farsightedness caused by loss of elasticity of the lens of the eye, occurring typically in middle and old age.

Gustatory functions to..?

gustatory functions to give a person the perception of taste. The gustatory cortex works with the taste buds to create the taste sensation. The tongue is covered with taste buds, and taste buds in different areas of the tongue sense different types of flavors.

Functional impairments are strongly associated with poor nutrition....

impaired mobility or vision can interfere with the ability to procure and prepare food.

RISK FACTORS THAT AFFECT DIGESTION AND NUTRITION How does Alcohol and smoking alter or interfere with an older person's nutritional status?

interferes with the absorption of the B-complex vitamins and vitamin C.

RISK FACTORS THAT AFFECT DIGESTION AND NUTRITION Dysphagia can have functional impairments that include or affect ? Dysphagia increases the risk for ___________,_____________, _______________, and _____________.

is a functional impairment that can significantly affect chewing, digestion, nutritional status, and safe and effective swallowing. dysphagia increases the risk for malnutrition, dehydration, aspiration, and aspiration pneumonia.

Effects on Communication Presbycusis hearing loss is the diminished ability to hear __________________ sounds.

sensorineural hearing loss -Diminished ability to hear high-pitched sounds, especially in the presence of background noise (functional consequence) -For example, someone with presbycusis might interpret a sentence like "I think she should go to the store" as "I wish we could go to the show---diminished speech discrimination -usually present in both ears, but can be more severe in one ear.

Pathologic Conditions Affecting Vision: (3)

§Cataracts: leading, reversible cause of vision impairment §Age-related macular degeneration (AMD): leading cause of severe vision loss §Glaucoma: causes loss of peripheral vision leading to blindness if untreated

Planning for Wellness Outcomes: VISION

§Improved visual function §Increased safety §Improved independence in activities of daily living §Improved quality of life §Stress level §Knowledge: personal safety §Fall prevention behavior §Risk control: visual impairment

Pathologic Conditions Affecting Urinary Function: Urinary Tract Infections: Where are UTIs common?

•Common in long-term care settings CAUTI's occur when Indwelling catheter has been in place for 2 days or more, or within 1 day after the removal of a catheter

Risk Factors that Affect Sexual Function: Gender-Specific Conditions:? Effects of chronic conditions? Functional impairments?

•Gender-Specific Conditions In men, BPH can cause ED and ejaculatory dysfunction and can cause urinary incontinence as well, which can also interfere with sexual enjoyment. In women, sexual function can be affected by the increased susceptibility to urethritis and vaginitis from the thinning of the vaginal tissue the decreased amount and acidity of vaginal secretions. ---After intercourse, it can cause urinary urgency and burning and interfere with the enjoyment of sexual intercourse. •Effects of chronic conditions Detrimental effects on sexual wellness... (Pain, cancer, diabetes, cardiovascular disease, obstructive sleep apnea) -Diabetes and cardiovascular disease are risk factors for sexual dysfunction in both men and women. These diseases can cause ED, decreased arousal, orgasmic dysfunction, decrease vaginal lubrication, and pain. The side effects of these diseases, such as fatigue, depression, decreased desire, fear and anxiety can also affect sexual function. •Functional impairments ---Chronic conditions -COPD: can cause hypoxia and severe SOB -Arthritis: pain, stiffness, muscle spasms, and limited flexibility -Urinary incontinence: interfering with satisfaction -Medical conditions and adverse medication effects -Sensory impairments

Pathologic Conditions Affecting Sleep: Sleep Disorders

•Insomnia •Excessive daytime sleepiness •Obstructive sleep apnea (1) the involuntary cessation of airflow for 10 seconds or longer (i.e., apnea) and (2) the occurrence of more than five to eight of these episodes per hour. This condition occurs because the muscles responsible for holding the throat open relax during sleep and block the passage of air. Symptoms of OSA include: daytime fatigue, morning headaches, diminished mental acuity, and loud snoring punctuated by brief periods of silence ***Strong evidence links OSA to increased risk for all the following: stroke, hypertension, diabetes, depression, heart failure, atrial fibrillation, and cognitive impairment •Sleep-Related Movement Disorder Restless legs syndrome, also known as Willis-Ekbom disease, is a sensorimotor condition characterized by the following symptoms: -An almost irresistible urge to move the legs (or other body parts), usually accompanied or caused by unpleasant sensations, which are often described as itchy, crawling, burning, or creepy -Onset of symptoms occurs or worsens during rest or inactivity -Symptoms are relieved by movement, such as walking or stretching -Symptoms are worse in the evening or occur only at night Symptoms of OSA include daytime fatigue, morning headaches, lower mental acuity, and loud snoring with brief periods of silence In addition, the following health promotion interventions may alleviate symptoms: -Moderate amounts of regular exercise, such as walking or using a stationary bike -Stress reduction techniques, such as yoga or meditation -Gentle massage of legs -Soaking in warm bath -Avoiding alcohol and excessive caffeine Quitting smoking (if applicable)

EFFECTS OF AGE-RELATED CHANGES ON VISION

•Loss of accommodation is pesbyopia (presbycusis-hearing) which is the loss of the ability to quickly focus on an object at various distances. It begins in early adulthood and affects all people to some degree by their mid 50's. From a degenerative change in the lens and cilliary body. This causes people to hold objects further away to read. •Diminished Acuity: Snellen chart. Your vision vs. 20/20. Acuity gradually declines after age 30. Poor acuity has the biggest effect on night driving. •Delayed Dark and Light Adaption: The response to dim light decreases ~ 20 and more significantly after age 60. It is harder to adapt to headlights when driving. •Glare-beginning in the 50's people become more sensitive to glare. Hard to drive at night, read signs, and function in bright areas. Hospitals usually have more glare than homes. •Visual field becomes smaller between 40-50 and steadily declines after. Driving requires a good field of vision. •Depth perception-Locating objects in 3D. Helps you maneuver in your environment. Older adults can discriminate depths as well as younger adults. •Color Vision: Age-related changes interfere with color perception. Can make telling medications apart harder when they are known as the little white one and the little yellow one. •Critical flicker fusion: Perceives continuous light vs flashing. Emergency vehicles or road construction lights can be troublesome. •Slower visual information processing: Older adults need more time to process visuals. Especially when unfamiliar.