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Care of the Gerontological Patient, Legal/Ethical Considerations …

- - - - Chronic sputum with cough production daily for a minimum if 3 months in each of 2 consecutive years
        
        Increase in mucus, cilia projection
        
        Remove bronchial secretions
        
        Prevent obstruction of airway
        
        Maintain adequate fluid intake
        
        Thins mucous and makes it easier to expectorate
      - Chronic hypoxemia; "Blue Bloater"
        
        Assess for general cyanosis
        
        Around mouth, mucous membranes, palms of fingers
      - Cor pulmonale
        
        Watch for signs of fluid overload
      - Causes persistent, productive cough; wheezing; recurrent respiratory infections; SOB
      - Interventions
        
        Lowest FiO2 possible to prevent CO2 retention
        
        NC @ 2 L/min
        
        Decreased respiratory drive
    - - Reduced gas exchange surface area
      - Increased air trapping
      - Decreased capillary network
        
        Loses elasticity/capillaries of alveoli
        
        Where O2 exchange occurs
      - Increased work, increased O2 consumption
      - Assess:
        
        Barrel chest
        
        Pink Puffer
        
        distant quiet breath sounds. wheezes
        
        Pulmonary blebs CXR
      - Treatment:
        
        Postural drainage
        
        bronchodilators
        
        avoid stress
        
        Breathing exercises
        
        Pursed lip breathing
      - Causes
        
        Smoking
        
        Chronic irritation
        
        Chronic bronchitis
        
        Morphological changes in lung
- - - - Degenerative changes in the smooth muscle lining of the lower esophagus, resulting in weaker esophageal contractions and weakness of the sphincter
        
        When esophageal and stomach motility decrease, food can remain in the upper GI for a longer period of time
        
        Indigestion
        
        Can cause GER
        
        Can cause dysphagia
        
        Destruction of esophagus from acidic stomach contents
        
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        Aspiration
        
        Can lead to pneumonia and hypoxia
        
        Lack of oral hygiene can also cause aspiration pneumonia- chipped tooth or bacteria
    - - Impacts taste buds and decreases taste sensation
  - - - Distended rectum
      - Abdominal and rectal discomfort
      - Oozing of fecal material around the impaction, often mistaken as diarrhea
      - Palpable, hard fecal mass
      - Fever
    - - Frequency and character of bowel movements
      - Bowel elimination record
    - - Oil retention enema
      - Lubricated gloved finger
      - 50 mL hydrogen peroxide through rectal tube
    - - Contributing factors
        
        Inactive lifestyle
        
        Low fiber and low fluid intake
        
        Depression
        
        Laxative abuse
        
        Opiates, sedatives, aluminum hydroxide gels
        
        Dulled sensations
      - Interventions
        
        Eating a diet high in fiber and fluid and regular activity
        
        Raisins, prunes, dates, currants
        
        Providing a regular time for bowel elimination
        
        Mornings
        
        Rocking trunk from side to side
      - Education
        
        Laxatives
        
        Diarrhea from abuse
        
        Dehydration
- - - - Prolonged cardiac cycle
        
        More time needed for systole and diastole
        
        Unable to meet O2 demands of increased activity
        
        Dysrhythmias more common
        
        SVT
        
        Heart doesn't have enough time in diastole to fill
        
        Cardiac ischemia (TIA)
    - - Accelerated by HTN
      - Arteriosclerosis
        
        Peripheral Vascular Disease
        
        Edema
        
        Coronary Artery Disease
        
        Heart Failure
        
        Myocardial Infarction
    - - Diastolic murmurs occur in 50% of older adults
    - - Syncope, Falls
        
        Postural Hypotension
        
        Decline in SBP of 20 mmHg or more after changing positions
        
        Postural and postprandial hypotension due to increased intake of vasoactive meds and baroreceptor sensitivity
- - - - Hypertrophy of bladder muscle and thickening of the bladder
        
        Urinary frequency during day and at night (nocturia)
        
        May cause functional incontinence
        
        Inability to reach a bathroom in time
        
        Nocturia
        
        Increased risk for falls trying to reach the bathroom in dark
        
        Nightlights in bathroom
    - - Affects the body's ability to eliminate drugs
        
        Nurse should observe patient for signs of adverse drug reactions resulting from toxic accumulation
        
        Start patient on lower dosages of medications
        
        Consult BEERS criteria
  - - - Age-related changes may increase the risk of this problem
        
        Physical/Mental disorders such as delirium and dementia
      - Types
        
        Transient
        
        Acute and reversible
        
        Infections, delirium, medication reactions, excessive urine production, fecal impaction, mood disorders, inability to reach commode or urinal
        
        Established
        
        Chronic and persistent
        
        Stress
        
        Weak supporting pelvic muscles
        
        When intra-abdominal pressure placed on pelvic floor (sneezing, coughing, laughing) urine is involuntarily lost
        
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        Urgency
        
        UTI, enlargement of prostate, diverticulitis, pelvic bladder tumors
        
        Irritation or spasms of bladder wall
        
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        Overflow
        
        Bladder neck obstructions and medications
        
        Bladder muscles fail to contract or periurethral muscles do not relax
        
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        Neurogenic
        
        Cerebral cortex lesions, MS, and other disturbances along neural pathway
        
        Inability to sense the urge to void or control urine flow
        
        Functional
        
        Dementia, disabilities that prevent independent toileting, sedation, inaccessible bathroom, and medications that impair cognition
        
        Factors interfering with ability to reach a bathroom
        
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        Mixed
        
        Combination of factors
- - - - Decreased calcium absorption
        
        Increased risk for falls and fractures
        
        Important to exercise to promote bone formation
    - - Osteoarthritis
        
        Progressive deterioration and abrasion of joint cartilage, with the formation of new bone at the joint surfaces
        
        Does not cause inflammation, deformity, or crippling
        
        Disequilibrium between destructive and synthetic elements leads to a lack of homeostasis necessary to maintain cartilage, causing joint changes
  - - - Uric acid crystals are deposited in and around the joints causing severe pain and tenderness of the joint and warmth, redness, and swelling of surrounding tissue
- - - - Transitional stage between normal cognitive aging and dementia in which person has short-term memory impairment and challenges with complex cognitive functions
        
        Dementia
        
        Cause
        
        Damage to brain tissue due to Alzheimer's or other degenerative diseases, circulatory problems, lack of oxygen, infection, trauma, hydrocephalus, tumor, alcoholism, etc.
        
        Onset
        
        Slow; months to years before symptoms are evident
        
        Mental status
        
        Poor short and long term memory, disoriented, confused, difficulty finding proper word use, impaired judgement, problems with arithmetic and problem-solving, personality changes
        
        LOC
        
        Normal
        
        Behavior
        
        Inappropriate; may be unsteady on feet, have difficulty with coordinated movements
        
        Recovery
        
        Progression of disease may be slowed with medication but cannot be reversed; usually continues to worsen
        
        Types
        
        Alzheimer's
        
        B-amyloid proteins and neurofibrillary tangles
        
        Loss/degeneration of neurons and synapses, reduction in seretonin receptors, seretonin uptake in platelets, production of acetylcholine and acetylcholinesterase, and choline acetyltransferase
        
        Possible causes
        
        Chromosomal abnormalities associated with Down syndrome
        
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        Free radicals
        
        Slow-acting virus causing neurofibrillary tangles
        
        Treatment
        
        Clinical trials
        
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        Medication
        
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        Vascular
        
        Small cerebral infarctions
        
        Frontotemporal
        
        Neuronal atrophy affecting the frontal lobes of the brain; behavioral abnormalities
        
        Lewy body
        
        Subcortical pathology and presence of lewy body substance in cerebral cortex
        
        Creutzfeldt-Jakob disease
        
        Transmitted through a slow virus; severe neurological impairment
    - - Increased risk of strokes
        
        Risk Factors
        
        HTN, severe arteriosclerosis, diabetes, gout, anemia, hypothyroidism, silent MIs, TIAs, dehydration, smokers
        
        Types
        
        Ischemic
        
        Thrombus or embolus
        
        Hemorrhagic
        
        Ruptured cerebral blood vessel
        
        Loss of elasticity of blood vessels as we age
        
        Interventions in acute phase
        
        Maintain a patent airway, provide adequate nutrition and hydration, monitor neurologic and vital signs, prevent complications associated with immobility, good skin care, frequent turning, assess for an over distended bladder, eye irrigations and eye pads, frequent oral hygiene
        
        To minimize limitation
        
        Talk to pt during routine activities, briefly explain basics of what occurred, the procedures being performed, and the activities to expect, speak distinctly but do not shout, devise an easy means of communication, minimize environmental noise, aim for consistency of care, use objects familiar to pt, supply sensory stimulation, provide positive feedback, expect and accept errors
        
        Warning signs
        
        light-headedness, dizziness, headache, drop attack, memory and behavioral changes
- - - - Increased risk for infection and effects of infection
    - - Risk for infection becomes significant
    - - Diseases/Conditions may not be caught as early since this is one of the first stages of most processes
- - - - Ability to respond to cold temperatures is reduced & response to heat it altered
        
        Increased risk for hypo- and hyperthermia
        
        Hypothermia: Body heat is lost faster than reproduced
        
        Heated blankets, multiple layers
        
        Hyperthermia: Body heat is produced faster than it is lost
        
        Rapid cooling
        
        Normal body temperatures are lowered in older age ranging from 96.9 deg F to 98.3 deg F
    - - Pruritis
        
        Can be caused by:
        
        Excessive bathing and dry heat
        
        Dry heat from sun could also cause skin cancer
        
        Can also be caused by Diabetes, arteriosclerosis, hyperthyroidism, uremia, liver disease, cancer, pernicious anemia
        
        May lead to breakage and infection of the skin and skin tears
        
        Older adults have a decrease in functioning of the immune system, therefore fighting the infection could be a challenge and cause serious issues
        
        Treatment
        
        Bath oils, moisturizing lotions, and massage
        
        Vitamin supplements, high-quality vitamin-rich diet
        
        Antihistamines, topical steroids
      - Pressure injury on bony prominences
        
        Frequent turning and making sure patient is clean
- - - - Light perception threshold decreases
      - Dark and light adaptation takes longer
      - Difficulty with vision at night
    - - High pitches are diminished and the ability to discriminate tones is lost
        
        Changes may negatively impact communication
        
        Self-conscious of limitation and avoid interactions
        
        Social isolation, depression, risk of dementia
        
        Causes
        
        Exposure to noise from loud music, jets, traffic, heavy machinery, and guns cause cell injury and loss
        
        Patient care
        
        Audiometric examination
        
        Helping patient to deal with frustrations
    - - Clouding of lens or its capsule that causes lens to lose its transparency
        
        Causes
        
        Exposure to ultraviolet B
        
        Wear sunglasses
        
        Diabetes, cigarettes, high alcohol consumption, eye injury
        
        Symptoms
        
        Vision is distorted, night vision is decreased, objects appear blurred
        
        Increased risk for falls for older adults
        
        Increased risk for fracture
        
        Fractures can throw blood clots and cause a stroke or MI
        
        Nuclear sclerosis develops, causing lens of eye to become yellow or yellow-brown
        
        Treatment
        
        Surgery to remove lens
        
        Sunglasses, sheer curtains over windows, furniture placed away from bright light, several soft lights
        
        Nursing Interventions
        
        Face the person when speaking
        
        Use several soft lights
        
        Use large print reading material
        
        Place frequently used items within visual field
- - - - Intercourse can be uncomfortable (dyspareunia) for older women
      - Vaginitis
        
        Vagina is easily irritated from increased fragility
        
        Soreness, pruritus, burning, foul-smelling discharge, and a reddened vagina
        
        Local estrogens in suppository or cream form for treatment
        
        Altered receptors for hot and cold temperatures can reduced pain sensation predisposes older adult to burns from solutions excessively hot for the fragile vagina
        
        Avoid perfumed soaps and sprays and douches
        
        Wear cotton underwear, keep genital area clean and dry, and use lubricants
    - - Some of prostate tissue is replaced with a fibrotic tissue
        
        Benign Prostatic Hyperplasia (BPH)
        
        Enlarging prostate puts pressure on urethra
        
        Hesitancy, decreased force of urinary stream, frequency, nocturia
- - - - Lower BMR
      - Reduced radioactive iodine uptake
      - Less secretion and release of thyrotropin
        
        Hypothyroidism
        
        Primary or secondary
        
        Primary
        
        Low free T4 and elevated TSH
        
        Secondary
        
        Low T4 and Low TSH
        
        Symptoms
        
        Fatigue, weakness, lethargy
        
        Depression and disinterest in activities
        
        Anorexia
        
        Weight gain and puffy face
        
        Impaired hearing
        
        Periorbital or peripheral edema
        
        Constipation
        
        Cold intolerance
        
        Dry skin and coarse hair
        
        Myalgia, paresthesia, ataxia
        
        Treatment
        
        Synthroid or Thyroxine
    - - Reduces secretory activity of adrenal gland
        
        Reduced secretion of estrogen, progesterone, androgen, 17-ketosteroids, and glucocorticoids
    - - Diabetes Mellitus
        
        Increased amount of fat tissue present in older persons who are obese and inactive
        
        First-degree relative with diabetes
        
        Indications of diabetes
        
        Orthostatic hypotension, periodontal disease, stroke, gastric hypotony, impotence, neuropathy, confusion, glaucoma, contracture, infection
        
        Diagnosis if one of the following criteria exists
        
        Symptoms of diabetes and a random blood glucose of > or equal to 200
        
        HbA1c > or equal to 6.5%
        
        Fasting blood glucose > or equal to 126 mg/dL
        
        Blood glucose concentrations 2 hours after an oral glucose intake of > or equal to 200 mg/dL during an oral glucose tolerance test
        
        Patient Education
        
        Self-care and monitoring
        
        Ability to handle a syringe and vial of insulin
        
        Repeat demonstrations
        
        Arthritis
        
        Ability to read calibrations on syringe
        
        Visual impairments
        
        Macular degeneration
        
        Hyperglycemia without glycosuria
        
        Finger-prick technique
        
        HbA1c < 7%
        
        Monitoring of triglycerides to watch for metabolic syndrome
        
        Exercise and nutrition
        
        Regular exercise
        
        Improves glucose tolerance, increases muscle strength, decreases body fat, improves maximal oxygen consumption, and improves lipid profile
        
        Maintain consistent daily food intake