older adult
72 yr old female with Parkinson's is embarrassed to wear adult pads. She is having increased tremors, difficulty walking, and get to the bathroom. Identify the type of incontinence
**
fall risk assessment
****look at slide show******
92 yr o with deminetia and has lost 10 lbs in one month what labs do you order?
**answer**
age for medicare and social security currently
65
average life expectancy for women and men
81 years women 76 men
sleep
A common report of insomnia and changes in sleep patterns are part of the normal aging process. Some commonly reported changes in sleep patterns are as follows ■ Stages 3 and 4 (deep sleep) decrease, and stage 1 (light sleep) increases. ■ Difficulty falling asleep ■ Nap more often during the daytime hours ■ Have frequent awakenings during the night ■ Insomnia related to pain or chronic health problems Ask the patient: ■ What time do you usually go to bed, and what time do you wake up? ■ Do you feel rested when you wake up in the morning? ■ Do you nap during the day? If so, how many times during the day and for what period of time? ■ TIP Adults with progressive dementia or Alzheimer's disease will sleep throughout the day and night. ■ Do you take any medication to help you fall asleep? ■ Do you have sleep apnea? If so, do you use a continuous positive airway pressure (CPAP) machine? concept of feeling rested is important in O.A. napping- 20 minutes is good but 5hrs is too much and may indicate depression apnea-most know by time they are 70 or 80
medication
As one ages, organ systems begin to decline, and the intake of prescribed and over-the-counter (OTC) medications increases. Nurses must perform a thorough medication assessment. The elderly constitute 12 percent of the U.S. population and consume 31 percent of the nation's prescribed drugs (Lehne, 2013). Polypharmacy continues to be an ongoing problem among older adults. Polypharmacy is frequently identified by the use of: ■ multiple medications ■ multiple prescribers ■ several filling pharmacies ■ too many forms of medication ■ medications taken when there is no clinical indication ■ multiple dosing schedules Perform a thorough medication assessment. -recommended that the older adult bring with her or him all the medications taken on a regular basis or bring a written list for your review.
Barthel Index
Barthel index of basic activities of daily living (ADL) is considered a "core" to functional assessment ... • Bowels-Bladder • Transfer-Toileting • Feeding-Grooming • Bathing-Dressing • Mobility-Stairs
What is dual energy x-ray absorptiometry (DEXA)?
Dual-energy x-ray absorptiometry (DEXA) is a form of x-ray technology that is used to measure bone loss. DEXA is the gold standard method for the evaluation of diagnosis and fracture risk in elderly and to measure bone density.
elder abuse
During the assessment, it is essential that nurses assess for signs of elder abuse. Elder abuse is a growing, underreported problem. This type of abuse can affect people of all ethnic backgrounds and social status and can affect both men and women (National Center on Elder Abuse [NCEA], n.d.). The older adult is particularly vulnerable to elder abuse because they are more likely to suffer acute or chronic conditions resulting in physical or mental impairments. ■ TIP Most elder abuse is committed by relatives, spouses, significant others, and caregivers. The responsibilities and demands of elder caregiving, which escalate as the elder's condition deteriorates, can be very stressful to the caregiver. According to the National Center for Elder Abuse (NCEA), there are seven types of elder abuse (Table 24-1). ■ TIP Many older adults do not report the abuse because they fear retaliation from the abuser; others believe that if they turn in their abusers, no one else will take care of them. Parents who are being abused by their children do not report because they do not want their children to get in trouble with the law. It is essential for nurses to be alert to signs of elder abuse by: ■ listening to seniors and their caregivers ■ intervening when you suspect elder abuse ■ educating others about how to recognize and report elder abuse. ■The laws in most states require helping professions in the frontline health-care providers to report suspected abuse or neglect. These professionals are called mandated reporters
Psychosocial Assessment
Each population has special needs and considerations. The physical assessment is the same as for any adult except there are some special gerontological considerations. Particular attention should be given to the following assessment areas: living arrangements, functional assessment, falls, health promotion, driving, alcohol use, elder abuse, and sexuality.
what pain too do you use with patients slight dementia or are illiterate
FACES
fasting blood sugar and hemoglobin A1C
Fasting blood sugars and hemoglobin A1C to assess diabetes
functional incontinence
Functional incontinence occurs more often with older individuals with chronic arthritis, Parkinson's disease or Alzheimer's disease; these individuals are unable to control their bladder before reaching the bathroom due to limitations in moving related to a physical or cognitive disability.
functional assessment
Functional status is the patient's ability to care for him- or herself and meet essential tasks for daily life. Screening older adults for functional limitations has been identified as a "vital sign" . The Barthel index of basic activities of daily living (ADLs) is considered a "core" to functional assessment (Appendix 24-1). The focus of the assessment must be on the patient and how he or she perceives his or her current level of functioning.
Geriatric syndrome and signs and symptoms
Geriatric syndrome--- is a term used to capture those clinical conditions in older persons that do not fit into discrete disease categories --BOX 24-1 s&s Anorexia Dementia Dizziness Falls Frailty Gait instability Impaired cognition Impaired hearing Impaired vision Malnutrition Parkinson disease Pressure ulcers Sleep complaints Vertigo
alcohol use
In this population, alcoholism is more challenging to assess and diagnose due to chronic illness, polypharmacy, and cognitive disorders. Older adults are more sensitive to the effects of alcohol. Women are more sensitive to the effects of alcohol than men. As people age, there is a decrease in the amount of water in the body, so when older adults drink, there is less water in their bodies to dilute the alcohol that is consumed. This causes older adults to have a higher blood alcohol concentration (BAC) than younger people after consuming an equal amount of alcohol (NIH Senior Health, 2015). Medications can have adverse interactions with alcohol. The older adult alcoholic usually: ■ is male ■ is grieving due to loss of spouse, family, or friends ■ is socially isolated and lonely ■ has comorbid psychiatric illness such as depression or anxiety ■ has family history of alcohol dependence ■ precipitated by losses, loneliness, social isolation, medical or psychiatric comorbidities ■ has poor personal hygiene (Mahgoub, 2009). The National Institute of Alcohol Abuse and Alcoholism (2011) makes the following recommendations: ■ Adults over age 65 who are healthy and do not take medications should not have more than: □ three drinks on a given day □ seven drinks in a week. Assess older adults for alcoholism using the CAGE questionnaire.
lipid pannel
Lipid panels to measure cholesterol and triglyceride levels
mixed incontinence
Mixed incontinence shares the causes and symptoms of both stress and urge incontinence.
Driving With Advancing Age
Motor vehicle injuries are the leading cause of injury-related deaths among 65- to 74-year-olds and are the second leading cause (after falls) among 75- to 84-year-olds. While traffic safety programs have reduced the fatality rate for drivers under age 65, the fatality rate for older drivers has consistently remained high (AARP, 2013). When you take the patient's history, be alert to "red flags"—that is, any medical condition, medications, or a symptom that can affect driving skills, either through acute effects or chronic functional deficits. Some symptoms to be alert to are: ■ impaired personal care such as poor hygiene and grooming ■ impaired ambulation such as difficulty walking or getting into and out of chairs ■ difficulty with visual tasks ■ impaired attention, memory, language expression, or comprehension Ask the patient: ■ Are you able to read signs easily? ■ Can you recognize someone you know from across the street? ■ Are you able to see street markings, other cars, people walking, especially at dawn, dusk, and at night? ■ How do you handle headlight glare at night? (National Highway Traffic Association, n.d.) The American Association of Retired Persons (AARP) (2010) has identified warning signs for when to stop driving. These are as follows: ■ Almost crashing, with frequent "close calls" ■ Finding dents and scrapes on the car, on fences, mailboxes, garage doors, curbs, etc. ■ Getting lost, especially in familiar locations ■ Having trouble seeing or following traffic signals, road signs, and pavement markings ■ Responding more slowly to unexpected situations, or having trouble moving their foot from the gas to the brake pedal; confusing the two pedals ■ Misjudging gaps in traffic at intersections and on highway entrance and exit ramps ■ Experiencing road rage or causing other drivers to honk or complain ■ Easily becoming distracted or having difficulty concentrating while driving ■ Having a hard time turning around to check the rear view while backing up or changing lanes ■ Receiving multiple traffic tickets or warnings from law enforcement
inspecting face
NORMAL FINDINGS ■ Face (round, oval, or square) ■ Bilaterally symmetrical facial structures ■ Nasolabial folds and palpebral fissures equal ■ Expression relaxed ■ No involuntary muscle movement; no visible pulsations ■ Skin smooth and clear ■ No edema ABNORMAL FINDINGS ■ Asymmetry of the face may be related to abscess, infection, enlargement of parotid gland, neurological disorders. ■ Flat affect may indicate depression. ■ Parkinson's disease causes a "masklike" facial appearance. ■ Kidney diseases may cause swelling of the face or around the eyes (periorbital edema).
inspecting and palpating the skin
NORMAL FINDINGS ■ Good hygiene, no odors ■ Uniform color ■ Skin warm, moist ■ No abnormal lesions (see Abnormal Findings) ■ Nevi are uniform brown color, regular borders, less than 0.6 cm. ■ Acrochordon (skin tag) is composed of skin and subcutaneous tissue; soft hanging skin commonly occurring on the trunk, armpits, and under the arms (Fig. 24-7). ■ Solar lentigo (liver spots) are hyperpigmented macular lesions commonly seen on the exposed body surface areas (Fig. 24-8). ■ Cherry hemangiomas are small, bright cherry red spots seen on the trunk and extremities; usually are the size of a pinhead or one-quarter-inch diameter (Bermin, 2012) (Fig. 24-9). ■ Seborrheic keratosis are noncancerous pigmented waxy lesions; color ranges from light tan, brown, to black (Fig. 24-10). ■ Cutaneous horn is caused by an overgrowth of keratin that resembles a miniature horn; may be normal or malignant; vary in color from yellow to brown or black; referral to a dermatologist is recommended (Stoppard, 2014) (Fig. 24-11). ■ Senile purpura are areas of ruptured fragile capillaries and bruising of the skin; caused by loss of subcutaneous fat ABNORMAL FINDINGS ■ Changes in a pre-existing lesion. Use the ABCDE mnemonic to note changes (Box 24-3) in lesions that may indicate signs of a malignancy. ■ Actinic keratosis is a rough, scaly patch that most often develops on chronically sun-exposed areas such as the face, the dorsum of the hands and forearms, the upper chest, and the scalp of bald men (Sarnoff, 2014); often described as "stuck-on cornflakes" (Wheeler, 2009); commonly seen in Caucasian older adults. ■ TIP Basal cell carcinomas are the most common cancerous lesions seen in the older population. ■ Shingles (herpes zoster) is caused by the varicella-zoster virus, the same virus that causes chicken pox. The vesicular lesion develops into a rash that presents on one side of the body where the dormant virus reactivates; the rash is painful and forms blisters and may take weeks to resolve. Older individuals are at greater risk because their immune response decreases with age (Fig. 24-13). ■ TIP The vaccine for shingles (Zostavax) is recommended for use in people 60 years old and older to prevent shingles. The older a person is, the more severe the effects of shingles typically are, so all adults 60 years old or older are encouraged to get the shingles vaccine (CDC, 2016). ■ Petechiae or purpura may indicate a clotting or liver disorder. ■ Erythema may indicate inflammation or excoriation or open wounds of the skin ■ Tenting of skin commonly seen in the abdomen in older adults may indicate dehydration or weigh
head hair and scalp
NORMAL FINDINGS ■ Head is symmetric, midline, round. ■ Normocephalic; a person's head and all major organs of the head are in normal condition and without significant abnormalities. ■ Head erect and still; no involuntary movements ■ No pain, tenderness, masses, or depressions during palpation ■ Hair clean, curly, or straight texture; uniform thickness and distribution ■ Color brown, black, blonde, red, white, or gray ■ Scalp clean and intact, no lesions ABNORMAL FINDINGS ■ Pain ■ Tenderness ■ A mass ■ Involuntary movements ■ Depression of the skull ■ Alopecia, defined as hair loss, may be due to nutritional deficiencies, medications, illness, endocrine disorders, radiation, or the physiological changes of aging. ■ Alopecia areata of scalp, or spot baldness, is a loss of hair in patches involving the scalp or beard; thought to be related to an autoimmune disorder. ■ Folliculitis is inflammation of a hair follicle developing on the face, arms, legs, or buttocks; white pustules appear around the hair follicle; may be related to Staphylococcus aureus infection. ■ Seborrheic dermatitis is a chronic, greasy scale that accumulates and thickens on the scalp with or without redness; may extend to the forehead, eyebrows, and face.
finger and toenails
NORMAL FINDINGS ■ Nails smooth, short, uniform thickness, well groomed ■ Nail base angle 160 degrees ■ Firmly adhere to the nailbed ■ Nailbeds pink ■ Capillary refill less than 3 seconds ■ Nontender to palpation ■ No redness, exudates, or signs of infection or inflammation ■ Dark-skinned individuals have pigmented bands in their nails. ■ Nails may become brittle or hard and thick, especially the toenails. ■ Color of the nails may change from clear to dull or opaque color. ■ Longitudinal ridges may form; tips of fingernails may become brittle and split. ABNORMAL FINDINGS ■ Changes in color, shape, texture, or thickness indicate an abnormal finding. ■ Beau's line is a white, horizontal groove across the nailbed; usually caused by disease, toxic reaction, or trauma. ■ Onychomycosis is thickening, yellow discoloration, and scaling of the nailbed due to a fungal infection; more common in diabetics and older adults
inspecting buccal mucosa
NORMAL FINDINGS ■ Pink, smooth, moist, no lesions, swelling, or bleeding ■ Tight margin around each tooth ■ No tenderness with palpation ■ Halitosis, or bad breath, may occur due to a dry mouth ■ Xerostomia is dry mouth; less saliva is being produced ABNORMAL FINDINGS ■ Red, inflamed, or bleeding mucosa; lesions ■ Tenderness with palpation □ Aphthous stomatitis (canker sore) is the most common nontraumatic form of oral ulceration with 20 to 40 percent incidence in the population; ulcer formation is the main clinical presentation (Jefferson, 2011). □ Thrush is a candidiasis fungal infection that creates thick, white to yellow patches on the tongue or buccal mucosa; occurs frequently with a weakened immune system and antibiotic therapy. □ Gingivitis is the mildest type of periodontal disease; red, swollen, bleeding gums. □ Gingival hyperplasia is an enlargement or overgrowth of the gum tissue; firm and nonpainful; may be related to systemic illness, side effects of medications such as phenytoin (Dilantin), and poor oral hygiene. □ Periodontal disease is a chronic infection of the gums and is caused by bacteria in the plaque on teeth. A dry mouth can cause dysphagia, difficulty swallowing. The older adult may take several medications of which one of the side effects causes a dry mouth. This may lead to anorexia (decreased appetite) and weight loss. Monitor patients for unintentional weight loss. Calorie counts and or food diaries may be helpful assessment tools.
inspecting hard and soft palates
NORMAL FINDINGS ■ Transverse rugae, irregular ridges are firm, pink to light red; moist ■ No tenderness ■ Soft palate is pink, moist; no lesions or ulcerations ■ Integrity of hard and soft palate intact ■ Nodular bony ridge down the middle of the posterior hard palate ABNORMAL FINDINGS ■ Deep red color, ulcerations, lesions, or growths □ Hard palate is a shade of yellow if jaundice is present.
inspecting and palpating tongue
NORMAL FINDINGS ■ Uvula rises midline symmetrically; glossopharyngeal (CN IX) and vagus (CN X) nerves intact ■ Throat pink ■ Tonsils pink; may partially protrude or be absent ■ Presence of a gag reflex ABNORMAL FINDINGS ■ Asymmetrical rise of the uvula ■ Throat deep red, inflamed, with drainage ■ Throat pain, dysphagia ■ Tonsils protruding with or without drainage
Pain assessment
Older adults are able to give reliable self-reports of levels of pain using different measures. (See Pain Assessment Chapter 7.) ■ When assessing pain in the older adult, be alert to the cognitive status of the patient (Malstrom & Tait, 2010). ■ Older adults may not be able to report their pain accurately; some may be unwilling to report pain (Tsai, 2011). ■ Close observation of the patient's nonverbal body language and behavior is essential when assessing this type of patient. Examples of nonverbal body language are restlessness, facial grimacing, frequent change in positions, and incomprehensible sounds.
eyes and aging
Older adults have difficulty adapting to darkness; there is an increased risk of stumbling or falling when moving from dark to light environments and vice versa ■ Cornea curvature decreases and sight begins to decline. ■ Slower pupillary reflex ■ Pupils are smaller but equal in size; may react more sluggishly to light ■ Loss of color discrimination ■ Decreased production of lacrimal (tear) secretions; eyes become drier ■ Decreased orbital and ciliary muscle strength ■ Increased opacity and clouding of the lens; lens loses its elasticity The older adult has a need for brighter light; as people age, seeing in dim light becomes more difficult because the lens tends to become less transparent Visual changes among aging adults include problems with reading speed, seeing in dim light, reading small print, and locating objects
cultural considerations
Older adults may be part of a cultural group that values specific healthcare beliefs and practices (Wallace, 2008); a cultural assessment will help to identify specific healthcare practices. English may be a second language for older adults and the patient may have difficulty understanding (Jimenez, Cook, Bartels, & Alegria, 2012). If English is a patient's second language, an interpreter may be needed to obtain a health history. Some cultures designate a specific family member to make all the decisions; some cultures believe that the older adult should not be told his or her diagnosis and that it should only be shared with family members (Wallace, 2008); this needs to be respected. The American Psychological Association (2013) reports: older Americans are predominantly Caucasian, but the demographics of older America will undergo a dramatic transformation in the next few decades. the number of older African Americans will triple by the middle of the next century, moving them from 8 to 10 percent of Americans over age 65. the older Hispanic population will increase 11-fold, going from representing fewer than 4 percent of today's older adults to representing nearly 16 percent of older adults. the onset of chronic illness in minorities is usually earlier than in Caucasians.
nutritional assessment
Older persons are vulnerable to malnutrition (WHO, 2016b), and inadequate micronutrient intake is common in older persons (Elsawy & Higgins, 2011). When assessing the older adult's nutrition, a nutritional assessment tool should be as ethnically specific as possible to account for cultural and anthropometric differences across populations (Tsai, Chang, Chen, & Yang, 2009). Modifiable risk factors such as weight, exercise, and diet influence health and the risk for developing chronic diseases. Older adults who are underweight (body mass index [BMI] less than 19) or overweight (BMI greater than 25) often have loss of muscle mass, a compromised immune system, and risk of health complications. Ask the patient: ■ How would you describe your appetite? ■ Do you have your own teeth or dentures? ■ Do you have any difficulty with chewing solid foods? ■ Do you have any difficulty swallowing fluids? ■ Do you notice any changes in your sense of taste? ■ Tell me what you ate yesterday starting from the time you woke up. older adults are vulnerable to: malunutrion and inadequate micronutrient intake normal part of age to lose some of taste bud sensation or may be something going on in mouth. Normal findings to use some flavors and you can suggest spicy foods.
overflow incontinence
Overflow incontinence is caused by weakened bladder muscle or urethral blockage, causing an overflow of urine; individuals cannot completely empty their bladder.
types of elder abuse
Physical abuse The use of physical force that can result in bodily injury, physical pain, or impairment Sexual abuse nonconsensual sexual contact of any kind with an elderly adult Abandonment The desertion of an older person by an individual who has assumed responsibility for providing care for the older adult or by a person with physical custody Emotional or psychological abuse The infliction of anguish, pain, or distress through verbal or nonverbal acts Financial or material exploitation The illegal or improper use of an older adult's funds, property, or assets Neglect The refusal or failure to fulfill any part of a person's obligations or duties to an older adult; refusal or failure to provide an elderly person with such life necessities Self-neglect A person's refusal or failure to provide himself/herself with adequate food, water, clothing, shelter, personal hygiene, medication, and safety precautions
when do you stop them driving
Red flags lots of fenderbenders they drive somewhere and dont know how they got there and they dont know why they drove out there perpheral vision decrease over time and it prevents from mirror use. reaction time **if you take license then you have to develop a plan** You can take away part of license to be restricted driving time
serum iron
Serum iron levels assess red blood cell function; a low iron level is indicative of iron deficiency anemia.
Sexulaity
Sexual health has long been considered within the functional health patterns of nursing assessment and management (Wallace, 2013). Sexuality is not widely covered in nursing education programs, especially in relation to the care of older adults, so nurses are often uncomfortable assessing sexual issues. Sexual interest and function is a very sensitive topic to discuss with the older patient. Older adults may not be as active as in their younger years but continue to have sexual relationships and sexual desire. Provide privacy and be sensitive to any discussion. Ask the patient: ■ Are you involved in an intimate or sexual relationship with a partner? □ Intimacy involves a physical communion with another person but also involves intellectual or emotional closeness; each component may be experienced separately with another person or two or three of the components may be shared with another person (Brown, 2012, p. 206). ■ Can you tell me how you express your sexuality? ■ What concerns or questions do you have about fulfilling your continuing sexual needs? ■ In what ways has your sexual relationship with your partner changed as you have aged?
skin changes in older adult
Skin changes are the most visible signs of aging that are influenced by environmental, genetic, and lifestyle behaviors. ■ The epidermal layer of skin becomes thinner and more fragile. ■ Blood vessels in the dermal layer become more fragile and have a tendency to rupture and pool throughout the dermal layer. ■ The number of nerve endings in the skin decreases, causing decreased sensation and sensitivity to pain. ■ There is decreased function of the sweat glands; decreased perspiration and sweating. ■ Sebaceous glands produce less oil; skin becomes dry and pale. ■ The subcutaneous fat layer thins providing less insulation. ■ Wrinkling of the skin is seen, especially in the chin and neck area. ■ TIP Smoking causes increased wrinkling and premature aging of the skin. ■ Skin pores become large and plugged with dead skin. ■ Aging pigmented spots or lesions may appear on the skin. ■ Narrowing of the arteries causes reduced peripheral circulation.
stress incontinence
Stress incontinence is leaking small amounts of urine with intra-abdominal pressure such as with coughing, sneezing, and exercising; may be related to the weakening of the pelvic floor muscles.
mini nutritional assessment (MNA) assessment tool
The Mini Nutritional Assessment (MNA) is the most validated nutritional screening and assessment tool that can identify geriatric patients age 65 and above who are malnourished or at risk of malnutrition. It consists of six questions and streamlines the screening process Assess for signs of poor nutrition: ■ Anorexia (decreased appetite) ■ Bleeding and inflamed gums ■ Brittle hair and nails ■ Pale conjunctiva ■ Decreased urinary output ■ Dry skin with decreased skin turgor ■ Dry cracked or chapped lips ■ Eyes appear sunken ■ Fatigue and weakness ■ Wounds that do not heal
kidneys and bladder and aging
The older adult may have a decline in kidney functioning; it is important to assess the amount of medications an older adult takes because drug excretion may be reduced causing drugs to accumulate in the system. ■ The number of nephrons and the overall amount of kidney tissue decreases, affecting the kidneys' ability to function properly. ■ Blood vessels supplying the kidney can become hardened, and the kidneys filter blood more slowly. ■ The muscles of the bladder weaken, and patients may experience incontinence or prolapse of the bladder; the bladder may not empty completely when urinating, and patients may have problems with urinary retention. Safety Alert Decreased renal output and glomerular filtration impair the kidney's ability to excrete sodium; this places the older adult at higher risk for hypertension; advise older adults to limit their salt intake. ■ Older adults have an increased risk for urinary incontinence and urinary tract symptoms due to the aging of the bladder muscle that leads to a decrease in the bladder's capacity to store urine. Urinary incontinence is involuntary urination. There are four types of incontinence:
Residential living
There are many available living arrangements for the older adult such as single family home in retirement communities, senior housing apartment communities, assisted living facilities, rest homes or boarding houses, and skilled nursing care. Ask the patient: ■ Where do you live? ■ Do you live alone? If not, with whom do you live? ■ Are you comfortable where you are living now? ■ Do you feel safe where you are living now? ■ If you had a medical emergency, who and how would you call for help? Older adults who live independently should know how and whom to call in case of a medical or environmental emergency. Patients may wear a medical alert device to call for help when needed. Nurses should assess and recommend such a device if the patient lives alone.
surveying the whole person
To assess the general well-being and behavior of the patient □ Physical appearance • Health: does the patient look healthy or ill? • Age: does the patient look his or her stated age? • Patient hygiene, grooming, appropriate dress for climate or season; note body odors and breath • Body structure: tall, short, muscular, thin, or overweight; symmetry of body structures • Posture: is the patient able to stand up straight? • Mobility: is the patient able to walk or in need of assistive devices? □ Behavior and mental status • Level of consciousness: alertness and orientation • Reliable or unreliable when answering questions • Behavior: calm, cooperative, eye contact, clarity of speech □ Facial expression: relaxed, stressed, frowning, facial grimacing, symmetrical □ Mood: happy, depressed, flat affect, agitated □ Speech: clear, difficulty articulating words, slurring speech NORMAL FINDINGS ■ Health: Appears healthy with no signs of illness or debilitation ■ Physical appearance: Age: patient looks stated age; hygiene: well groomed, appropriately dressed for climate, no odors; body structure: well built, symmetrical body ■ Mobility: gait steady and symmetrical, no difficulty walking; posture: stands straight, sits up straight without support; range of motion: ability to move all joints and extremities, actively participates in the assessment ■ Posture: able to stand up straight (Fig. 24-4) ■ Level of consciousness: alert and oriented × 4 (person, place, time, situation); calm and cooperative; may or may not have direct eye contact (depends on culture), speech clear, facial expression relaxed and symmetrical; mood calm; reports understanding reason for assessment ■ Reliability: understands questions and is able to answer ■ Facial expression: relaxed with no signs of discomfort ■ Speech: clear ■ Distress: no signs of general discomfort or pain; no signs of cardiac or respiratory distress Abnormal findings ■ Physical appearance □ Frailty, cachectic (wasting syndrome), tired, may be a sign of acute or chronic illness □ Age: patient looks much older than stated age; may indicate chronic stress or illness □ Patient hygiene: unkempt grooming, inappropriate dress for climate, clothing that is too tight or too loose, odors of the body or breath, weight gain or weight loss; may indicate mental status or cognitive dysfunction □ Body structure: tall, short, muscular, thin, or overweight ■ Mobility □ Gait and posture: Unsteady difficulty walking, limping, poor posture, use of assistive devices (walker, cane, wheelchair) (Chapter 16, Musculoskeletal System) □ Range of motion: inability to move all joints and extremities; unable to participate in the examination (Chapter 16, Musculoskeletal System) ■ Behavior and mental status □ Level of consciousness: disoriented, decreased mentation (Chapter 3, Psychosocial Assessment; Chapter 17, Neurological Assessment) □ Behavior: inappropriate (Chapter 3, Psychosocial Assessment; Chapter 17 Neurological Assessment) □ Mood: depressed, flat affect (Chapter 3, Psychosocial Assessment) □ Speech: difficulty articulating words, slurring speech (Chapter 17, Neurological Assessment) □ Unreliable when giving answers ■ Distress: signs of respiratory distress (Chapter 12, Respiratory System), signs of cardiac distress (Chapter 13, Cardiovascular System), signs of pain (Chapter 7, Pain Assessment).
Health promotion
Today, the older adult is more informed about health promotion and caring for self. The Internet has become a resource for many aging individuals to increase their knowledge about health promotion activities, medications, diseases, and treatments. Many older adults are motivated to become more health conscious about diet, exercise, the need to stay active, and the need to maintain relationships and connections. However, all adults may not be aware of the importance of staying involved. As one ages, his or her social network may diminish. The National Institute on Aging (2015) recommends provisions for social support and involvement in social activities to foster positive effects on the health and longevity in older adults. Information related to social interactions should be assessed. Ask the patient: ■ Do you have a spouse or significant other? ■ Whom do you consider to be your family? ■ Do you have friends who you socialize with? ■ Are you involved in any community activities or belong to a senior center?
urge incontinence
Urge incontinence is the sudden urge to urinate.
Normal vs abnormal recall problems **add**
abnormal recall problems-- recall problems and effect the activities of daily living ie. forgetting to bathe and cannot get dressed or they cannot do activites that they have been doing their whole life ie. paying bills normal-
prep for assessment
all pt should be addressed by their last name and with veterans you should always use their rank both out of respect. You want to use the highest level of respect to establish trust. You use pt first name only if they specifically say so. Not saying things like "sweetie" or things as such to not degrade or disrespect. You dont want them to feel that as they get older they're less. working with older adults takes time so be patient and allow for extra time---> biggest problem in patient care with older adults today. as we age it takes longer to physiologically process information. reaction time takes longer and processing of information takes longer. Set aside more time to assess the O.A. Reduce background noise--> harder to hear and its hard for older adults to process multiple things at once so TV, radio, etc. can effect if they answer you effectively and accurately older adults experience feeling cold more often---> so you must keep the room more warm. Keep room at 70 degrees and if below this they can become hypothermic and that can cause things such as confusion minimize position changes---> disorientating to them, make them more uncomfortable quicker
cultural considerations
cultural assessment will help identify specific health care practices of the older adult english may be a second language for older adults and the patient may have difficulty understanding some cultures designate a specific family member to make all decisions. If the older adult is competent to make decisions you go to the older adult not just immediately go to the spokesperson without talking to them. The only time we take away decision making features is when they cannot make decisions competently. in the US we are a ethnocentric and have a stigma on aging which can effect older adults feelings and effect their health care
what are not normal parts of aging
extreme weakening, frailness deafness blindness
what is the most common cause for losing hearing
hearing begins to decline because the cells within the organ or corti are not replaced ■ Hearing begins to decline because the cells within the organ of Corti are not replaced; therefore, there is a gradual loss of hearing as the person ages; decreased ability to discriminate sounds. ■ Tympanic membrane in the ear becomes dull gray and less flexible. ■ There is an increased accumulation of ear cerumen. ■ Increased hair growth occurs in the outer ear canal.
vitamin B12
help with cognition and muscle health older adult absorption can decrease so thats why we test Vitamin B12 levels are frequently monitored in the older adult; this vitamin is essential in DNA synthesis, hematopoiesis (creating new blood cells in the body), and central nervous system integrity. lack of vitamin B12 may cause neurological damage and a diagnosis of pernicious anemia.
inspecting teeth and lips
lips -NORMAL FINDINGS ■ Lips are symmetric ■ Upper lip is everted ■ Pink, moist, no lesions, swelling, or cracking of skin lips-ABNORMAL FINDINGS ■ Lips are inverted ■ Swelling, erythema, lesions, cracking of skin ■ TIP A sore that does not heal in the mouth requires further evaluation. □ Angular cheilitis are sore, cracked corners of the lips; commonly caused by yeast infections, dry mouth, or vitamin deficiency. □ Angioedema is edema of the lips; usually related to an allergic reaction. ■ Pallor of lips may indicate decreased perfusion related to respiratory or cardiovascular problems. □ Herpes simplex virus manifests with cold sores or blisters on the lips. teeth NORMAL FINDINGS ■ Color of teeth white to an ivory color (Fig. 24-15) ■ TIP Teeth may be stained yellow from smoking or brown from drinking tea or coffee. ■ Clean, free of debris ■ Smooth edges ■ 32 teeth or 28 teeth if wisdom teeth have been removed □ The upper incisors should overlap the lower incisors; back teeth should meet. teeth ABNORMAL FINDINGS ■ Loose, broken, painful teeth; surfaces of the teeth may be worn off and decaying (Fig. 24-16). ■ Malocclusion of the teeth ■ Loss of teeth or rotting teeth ■ Gums begin to recede trapping food and causing decay, increasing the risk for periodontal disease. ■ Ill-fitting dentures cause difficulty eating.\ ■ Missing teeth, discolored teeth, or no teeth ■ Teeth appear longer, gums recede. ■ Tooth decay and periodontal disease in the older adult can lead to loss of teeth and infection. --Periodontal disease has also been linked to stroke and coronary artery disease (CAD); the more severe the periodontitis, the greater the risk for heart problems --Poor fitting dentures, fewer or no teeth may attribute to unintentional weight loss. ■ Taste buds decrease causing a decreased sensation of taste. One type of taste disorder (dysgeusia) is characterized by a persistent bad taste in the mouth, such as a bitter or salty taste. It occurs in older people, usually because of medications, poor nutrition, smoking, or oral health problems
collecting heath history
may be challenging for both patient and nurse older adults may have atypical presentations what you're seeing may not be a typical of that issue ---> they may have stomach ache but that may be ulcer or just nervousness O.A. will often share lifetime stories and reminisce. Its critically important O.A. process their life but you must time manage--> "thats a great story, I dont have time to fully and actively listen to your story but I will come back and we can pick up where we left off. I am interested in hearing your story"--> you could use volunteers to come in and talk. You can also ask family to bring in photos to make a scrapbook or something Make sure the patient is reliable---> dont bypass the adult immediately and go to family. Listen to the older adult first. The best way to assess reliability is to ask the patient questions to which you can confirm the answers. For instance, asking the patient's name, date of birth, place of residence, date and time, or names of his or her children or significant other; use secondary resources to validate the information is correct. Explain what you are doing in simple terms Ask short, simple, clear, open-ended and focused questions Secondary sources may be needed to obtain the healthy history ---> you only can ask questions with relation to HIPPA** Ask more about this Obtaining a family health history for familial risk factors and psychosocial history is necessary in a comprehensive assessment. However, it may be difficult for the older adult to recall specific information. respect wants of patient maybe they dont want their kids there for whatever reason (invasive procedure, or general privacy). If family is overstepping you can ask them to step out. Older adults may have difficulty recalling information --> normal for aging. Normal recall problems ■ Introduce yourself and tell the patient the purpose of your encounter. ■ Respect every patient. Most older adults grew up in a time when one would not think of addressing an older adult by his or her first name (Nicklin, 2006). All patients should be addressed by their last name out of respect, unless they specifically say to call them by their first name. ■ Do not use medical jargon. ■ Working with older adults takes time; be patient and allow for extra time. ■ Communicate with the patient in a compassionate and caring manner; make sure the patient hears and understands you. ■ Reduce background noise so the patient is able to hear your questions clearly. ■ Older adults experience feeling cold more often than the middle-aged adult. Provide a warm, comfortable environment. ■ Be observant to whether the patient becomes short of breath during the interview; this may be a sign of respiratory disease. ■ Minimize position changes; assist the patient as needed with position changes. ■ Older individuals may be cognitively impaired making it difficult to assess the patient. (See Chapter 2.) ■ Communicate directly with the older adult; if cognitively impaired, the patient's significant other, family member, or caregiver may help to provide information. However, you still should ask the patient's permission. ■ Patients with dementia or Alzheimer's disease may be uncooperative or restless during the assessment; be calm, reassuring and use clear, simple, one-step directions. ■ The older adult may need assistance getting undressed and dressed as well as changing positions.
what should nurses know about older adults
older adults want to maintain their quality if life for as long as they are physically and mentally able to care for themselves nurses should know the physiological changes occurring as individual age their are older adults involved in every aspect of healthcare so they must know how to help older adults
age to be considered older adult
over 65
creatinine and blood urea nitrogen
tell you how the kidney and liver are function critical in ICU as we age kidney function can go down and it you are given certain medications this can effect how much you will give **you give med with older adults slow and small** Blood urea nitrogen (BUN) and creatinine levels to assess kidney functioning and for dehydration
INR
tells you how well the the blood is coagulating, how long it takes to clot International normalized ratio (INR) is a test to measure blood clotting; used to monitor patients who are on warfarin (Coumadin), an oral anticoagulant to prevent blood clots.
complete metabolic pannel
this is a blood test to look at the patients fluid and electrolyte levels There are no significant changes in laboratory data in the older adult; however, some changes are affected by the physiology of aging ■ Complete metabolic panel to assess electrolytes and kidney functioning
Because anemia is common in older adults, some levels that you may assess are
vitamine B12 Serum iron levels
when do you take away decision making?
when they are incompetent in their own decisions making healthcare power of attorney is the one to make health care decisions and this will be the only person with authority. This may not be the spouse. If there is not power of attorney **
albumin and protein levels
■ Albumin and protein levels to assess nutritional stores older adults may be at risk for altered nutritional status
aging and respiratory system
■ Bone structure and density decrease in the thorax and vertebrae decreasing lung expansion. ■ Vital capacity of the lung decreases. ■ The number of alveoli decrease resulting in decreased perfusion and exchange of oxygen and carbon dioxide at the alveolar level. ■ Lungs have less recoil and elasticity; causes increased demands to breathe and increased risk for shortness of breath. ■ Cough reflex is decreased. ■ Overall body changes in muscular strength, skeletal structure, and mobility, in addition to cardiovascular function, result in changes in pulmonary function. ■ Decreased thirst response, and less moisture within the mucous membranes of the upper and lower respiratory tracts contribute to thickened mucus (Frederick, 2014). ■ Lungs have less ability to fight off infection because the cells that sweep debris containing microorganisms out of the airways are less able to do so. ■ Older adults are particularly susceptible to respiratory diseases. Signs of infection many not be as obvious
musculoskeletal system and aging
■ Bones becomes less dense, and individuals are at risk for osteoporosis; bones that are weakened more than others are: □ femur at the hip □ the radius and ulna at the wrist □ the vertebrae of the spine ■ Bone changes may be influenced by decreased intake of calcium and vitamin D, medications (i.e., steroids), smoking, and lack of weight-bearing exercises. ■ Atrophy, skeletal muscle loss, or muscle wasting may occur. ■ Joint surfaces lose cartilage and connective tissue. ■ Muscles begin to lose fibers and degenerate. ■ Tendons and ligaments stiffen. ■ Height loss is related to aging changes in the bones, muscles, and joints
neurological system and aging
■ Brain and spinal cord begin to lose nerve cells and neural impulses begin to slow down causing a decrease in sensations and reflexes. ■ Brain loses weight as the nerve cells die; these nerve cells are not usually replaced. ■ Decline in balance
breasts and female reproductive system
■ Breast loses alveolar, glandular, and lobular tissue. ■ Breasts begin to sag due to relaxation of the suspensory ligaments. ■ Nipples become softer, smaller, and less erect. ■ Vulva and genitalia shrink; vaginal secretions diminish causing the vagina to become dry. ■ The vagina thins and loses elasticity due to decreased estrogen levels; uterine prolapse may occur. ■ Women may begin to have a decreased interest in sexual activity. ■ Atrophic changes occur in the external genitalia. ■ Pubic hair thins and starts to turn gray.
mouth and aging
■ Decreased sense of taste ■ Less saliva is produced causing a dry mouth. ■ Teeth wear down or fall out; gums recede increasing risk for periodontal disease.
peripheral vascular system and aging
■ Elastic arteries show two major physical changes with age; they dilate and stiffen. ■ Less arterial compliance and increased risk for calcification of the arterial walls (Lionkis, Mendrinos, Sanidas, Favatas, & Georgopoulou, 2012). ■ Vein valves weaken causing increased risk of varicosities especially in the lower legs. ■ Veins bulge on the upper arm extremities with thin, frail, older adults. ■ Lymph nodes may decrease in numbers with aging influencing the immune system to lose its ability to fight off infections. ■ Immune system is less tolerant of its own cells; there is an increased risk for autoimmune diseases to develop
abdomen and aging
■ Fatty tissue increases in the abdominal area and abdominal muscles weaken; older individuals have a tendency to have a "pot belly" appearance. ■ Gastric acidity is reduced in the elderly and may alter absorption of medications. less lactase is produced causing an increased risk for lactose intolerance. ■ Pernicious anemia is a vitamin B12 deficiency caused by a decreased number of red blood cells. ■ Liver cells (hepatocytes) decrease; decreased blood circulation through the liver. The liver is the major organ to metabolize medications; if liver function declines, drug metabolism declines, causing increased risk for elderly to have accumulation of drugs and place them at risk for drug toxicity. ■ Liver mass and blood supply in the liver decrease with age; the liver's metabolic and detoxification ability is reduced. ■ Gall bladder has decreased function with slower emptying time which causes increased accumulation of biliary sludge and risk for gallstones. ■ Pancreatic enzymes, amylase and lipase, decrease in production causing malabsorption of essential nutrients. ■ Intestines have decreased peristalsis related to weakening in the smooth muscle wall. ■ Older adults may suffer from chronic constipation; it is not uncommon to hear patients tell you that they use several laxatives; many times patients are embarrassed to report constipation; ask the patient about diet, exercise, and current medications and remedies to relieve constipation.
hair and aging
■ Less melanin is being produced causing hair to turn gray or white. ■ Men's eyebrows and hair in their ears and nose become bushier, longer, and coarser. ■ Women may begin to lose hair or develop facial hair due to hormonal changes. ■ A decrease in hormones causes thinning of hair or hair loss of the scalp, axillary, and pubic areas. ■ Senescent alopecia occurs when hair follicles produce thinner, smaller hairs or none at all.
nose and aging
■ Reduction in the surface area of the olfactory epithelium ■ Sense of smell decreases with a decreased ability to discriminate between smells (Blair, 2012) ■ Anosmia is the inability to smell
male genitalia and reproductive system
■ Scrotum thins and testes drop lower in the scrotal sac. ■ Penis shrinks and becomes smaller. ■ There is increased incidence of problems with erectile dysfunction. ■ Benign prostatic hypertrophy (BPH) is an enlargement of the prostate gland, may cause hesitancy, urine retention, and difficulty starting the stream in older men.
Cardiovascular system and aging
■ Vasculature and valves within the heart become more rigid. ■ The heart muscle becomes thinner, decreases in strength, and becomes less compliant; however, a thickening (hypertrophy) in the left ventricle is common. ■ Decrease in elasticity and increased stiffness of the arterial system ■ Loss of atrial pacemaker cells and bundle of HIS fibers can decrease the electrical activity in the heart; heart rate slows down. ■ The heart's pumping mechanism declines and arterial resistance increases causing an increase in blood pressure (BP). ■ The ability to meet cardiac output demands with increased workload is decreased. ■ A S3 or S4 heart sound may be a sign of heart failure (HF) or cardiomyopathy, and weakening of the heart muscle. ■ Jugular vein distention, swollen legs/feet, and/or shortness of breath may be signs of HF ■ The S4 heart sound is commonly heard due to decreased ventricular compliance and impaired ventricular filling; related to the stiffness of the ventricle as one ages. ■ A widened pulse pressure (difference between systolic and diastolic pressures) may occur which is related to vascular vessel stiffness. ■ More commonly, heart murmurs are auscultated related to changes in the structure and stiffness of heart valves. ■ Chest pain may indicate angina (tissue ischemia). ■ Atrial fibrillation (AF) is the most common arrhythmia in older adults (Tang, Ma, Dong, Yu, & Long, 2014). It is a fast irregular heartbeat. Older adults may experience symptoms of heart palpitations, dizziness, and shortness of breath. These patients are prescribed an anticoagulant to prevent blood clots from developing in the arterial system. ■ Plaque accumulation in the arteries causes atherosclerosis and coronary artery disease (CAD) ■Older adults have a higher risk for developing CAD and peripheral arterial disease (PAD) due to an accumulation of plaque in the arteries throughout their body.
