Pathological conditions in older adults

Chapter 14

Infection and Inflammation

Infection is one of the 10 most common causes of death in older adults.

The presentation of infections in older adults is often masked, which can lead to delayed treatment.

The immune system enables the body to defend itself against disease-causing microorganisms and other foreign bodies.

With aging the immune system exhibits a diminished ability to provide such protection.

Introduction

2

For infection to occur, there must be a reservoir of an infectious disease, a portal of entry, and a susceptible host.

Source may be a person’s own microbial flora (endogenous) or something in the environment (exogenous).

Nosocomial infections: acquired in the hospital

Community acquired: acquired outside the health care facility

The Chain of Infection

3

Changes in both cell-mediated and antibody-mediated immune response

Atrophy of the thymus

Diminished cellular (T cell–mediated) and humoral (B-lymphocyte) immunity

Production of autoantibodies increases

Skin becomes more fragile and prone to breakdown or abrasion.

Age-Related Changes in the
Immune System

4

Nutritional factors

Malnutrition

Iron and trace element deficiency

Psychosocial factors

Depression

Drugs

Complementary and alternative medications

Factors Affecting Immunocompetence

5

Every adult over the age of 65 should receive the influenza vaccination annually.

Community-acquired pneumonia is caused by multiple pathogens.

Pneumococcal vaccine is recommended for everyone over the age of 65.

Infection control measures help to reduce the risk of illness.

Many older adults present with atypical or diminished signs and symptoms.

Influenza and Pneumonia

6

Neoplasms occur with greater frequency in older adults.

Common types include lung cancer, breast cancer, and prostate cancer.

Presence of the cancer reveals presence of decreased immune response.

Cancer and cancer treatment can induce additional immune deficits.

Cancer

7

Symptoms: extreme fatigue, painful or swollen joints, unexplained fever, skin rashes, and kidney problems

Management objective is to control the severity of symptoms and prevent a flare.

Avoiding the sun, exercising, complying with drugs, limiting stress, and having regular health care visits

Systemic Lupus Erythematosus

8

Inflammatory polyarthritis of unknown cause

Symptoms: morning stiffness lasting for hours, tenderness, pain on motion, limited range of motion, and joint deformity in the small joints of the hands and feet

Treatment: physical therapy, first-line drugs for RA are nonsteroidal antiinflammatory drugs (NSAIDs), second-line drugs are known as disease-modifying antirheumatic drugs (DMARDs)

Rheumatoid Arthritis

9

Underrecognized problem among the older adult population: 31% of persons living with HIV and 17% of newly diagnosed cases are in those over the age of 50

The low clinical suspicion of HIV infection and delayed recognition of AIDS-defining infections contribute to the poor prognosis of HIV infection in older adults.

In older adults there is only a short interval from HIV infection to the development of AIDS and death.

Sex education, the use of condoms, and how and when to take an HIV test should be taught to older adults.

HIV in Older Adults

10

Nosocomial pathogen transmitted person to person, primarily from the hands of health care workers

Occurs when organism is present and normal flora of bowel are disturbed

The hallmark diarrhea is caused by a motility-altering factor that stimulates muscle contractions.

Consistent hand washing between contacts with patients and the use of gloves when handling body substances such as feces

Treatment: discontinue current antibiotic therapy, then treatment with oral vancomycin or fidaxomicin

Clostridium difficile

11

Risk factors: age more than 65 years, antimicrobial therapy, chronic renal failure, serious illness, and prolonged hospitalization

Transmitted person to person via hands of health care workers

Dedicated equipment, private rooms, and barrier precautions

Symptomatic patients should be treated with antibiotics indicated through culture and sensitivity.

Vancomycin-Resistant
Enterococcus (VRE)

12

Transmitted patient to patient via hands of health care workers

Risk factors: insulin-dependent diabetes mellitus, chronic hemodialysis, illicit intravenous drug use, prolonged hospitalization, prolonged antibiotic therapy, stays in the intensive care unit, burn unit, or with an infected patient

Private room and barrier protection

Symptomatic patients should be treated with antibiotics indicated through culture and sensitivity.

Methicillin-Resistant Staphylococcus Aureus (MRSA)

13

May not exhibit classic symptoms of infection

Fever—temperature increase may be limited, or no increase may occur at all, so low-grade fever must be taken seriously.

Changes in the behavior: increased malaise or fatigue, combined with other symptoms may indicate the onset of infection.

Fever and inflammation may be reduced, whereas the white blood cell (WBC) count may still reflect an increased value.

History of infections, current disease processes, and medications especially antiinflammatory and immunosuppressant drugs

Infection Nursing Management: Assessment

14

The risk factors determined during the assessment indicate potential nursing diagnoses

Inadequate nutrition

Potential for infection

Need for health teaching due to knowledge deficits of immunizations, nutrition, or protection against infection from oneself or others

Reduced social interaction associated with infection and immune status

Infection Nursing Management: Diagnosis

15

The nurse just admitted an older adult with new onset confusion and cough. The family states that the condition came on suddenly. The nurse completes a history and physical assessment on the patient. Discuss the following assessment findings, and state whether or not they are significant and why.

1. History of RA and taking low-dose prednisone

2. White blood cell count is 8.9.

3. Lives in a senior house and dines with other residents

4. Temperature is 99.8°F.

5. Last pneumonia vaccine was 5 years ago.

Quick Quiz!

16

ANS:

1. History of RA and taking low-dose prednisone

Immune function is already compromised by rheumatoid arthritis and steroids.

2. White blood cell count is 8.9.

Older adults may not have elevated WBC when infection is present.

Answer to Quick Quiz (1 of 2)

17

3. Lives in a senior house and dines with other residents

Living in close quarters with others puts older adults at risk for infectious disease.

4. Temperature is 99.8°F.

Fever may not be present.

5. Last pneumonia vaccine was 5 years ago.

Pneumonia vaccine should be administered every 5 years in patients with chronic illness.

Answer to Quick Quiz (2 of 2)

18

The patient with increased risk for infection will:

Avoiding primary or secondary infection

Maintaining or improving immune status

The patient will do the following:

Increase knowledge in areas related to infection prevention, maintenance of immune status, and health practices

Consumes a well-balanced, high-caloric diet on daily basis

Performs self-care activities with minimum energy expenditure and risk of injury

Infection Nursing Management: Planning and Expected Outcomes

19

Prevent exposure to infections

Enhance immune system to enable patients to better resist infections

Optimum nutritional status is important.

Resolve detected deficiencies

Meals on wheels, assistance with food preparation, or ability to visit a senior center nutrition site

Nursing Interventions

20

Based on patients’ responses in meeting their goals and outcomes

One standard for evaluation is whether a patient contracts an infection.

Evaluation

21

Chapter 10

Sleep and Activity

Regulation of sleep and wakefulness occurs primarily in the hypothalamus.

Sleep is a state of consciousness characterized by the physiologic changes of reduced blood pressure, pulse rate, and respiratory rate along with a decreased response to external stimuli.

Biologic Brain Functions and Sleep

2

Sleep begins with the four stages of non-REM sleep, continues with a period of REM sleep, and then cycles through non-REM and REM stages of sleep for the rest of the night.

Variations in the REM and non-REM sleep stages occur with advancing age.

REM sleep is interrupted by more frequent nocturnal awakenings, and the total amount of REM sleep is reduced.

The amount of stage 1 sleep is increased, and stage 3 sleep and stage 4 sleep are less deep.

Stages of Sleep and
the Older Adult

3

The sleep-wake cycle follows a circadian rhythm, which is roughly a 24-hour period.

The decrease in nighttime sleep and the increase in daytime napping that accompanies normal aging may result from changes in the circadian aspect of sleep regulation.

Sleep and Circadian Rhythm

4

Difficulty falling asleep, difficulty staying asleep, frequent nocturnal awakenings, early morning awakening, and daytime somnolence

May be transient, short term, or chronic

Affects the older adult’s quality of life with excessive daytime sleepiness, attention and memory problems, depressed mood, nighttime falls, and possible overuse of hypnotic or over-the-counter medications

Insomnia

5

Insomnia: the inability to sleep

5

Increased sleep latency, reduced sleep efficiency, nocturnal awakenings, increased early morning awakenings, and increased daytime sleepiness

Older adults awaken four or more times a night.

Daytime napping is common.

Daytime sleepiness may suggest underlying disease.

Other sleep changes are associated with chronic disease and other health problems.

Age-Related Changes in Sleep

6

Environment

Pain

Lifestyle

Dietary influences

Medication use and medical conditions

Depression and dementia

Factors Affecting Sleep

7

Schedule procedures and care activities to avoid unnecessary awakenings, modify environmental factors to promote a quiet, warm, relaxed sleep setting, and orientate older adults to the institutional setting.

Reduce noise: close doors, lower voices.

Reduce bright lighting at night.

Temperature: warmer is better than colder.

Nonpharmacologic and pharmacologic measures may be used to relieve pain.

Nursing Interventions for
Sleep Environment

8

Loss of spouse

Retirement

Relocation

Having a roommate in long-term care facilities

Dietary influences

Depression

Dementia

Lifestyle Changes Affecting Sleep

9

Sleep is influenced by what we eat and drink.

9

Which of the following are true statements about sleep in the older adult? (Select all that apply.)

Reduced REM sleep causes irritability or anxiety the next day.

Insomnia leads to an increase in daytime falls.

Older adults commonly take naps during the day.

Cooler temperature at night is better for sleeping.

Acute or chronic pain interferes with falling asleep.

Quick Quiz!

10

ANS: A, C, E

Answer to Quick Quiz

11

Recurrent episodes of cessation of respiration

Apneic episodes may last from 10 seconds to 2 minutes and range from 10 to 100 per hour of sleep.

Three types: central sleep apnea (CSA), obstructive sleep apnea (OSA), and complex sleep apnea

OSA most common in older adults

Sleep Apnea

12

Due to complete or partial airway obstruction that blocks air flow increasing respiratory efforts

Risk factors: obesity, short or thick neck, jaw deformities, large tonsils, tongue or uvula, narrow airway, deviated septum, smoking, hypertension, and cardiac disease

Symptoms: daytime fatigue; waking with a headache and sore throat or dry mouth, and confusion; trouble concentrating and irritability; and sexual dysfunction

Treatment weight loss, positioning on side, CPAP, mandibular advancement devices and surgery

OSA

13

Repetitive kicking leg movements throughout the night

May occur every 5–90 seconds and each kick causes a brief disruption of sleep.

Report insomnia and excessive daytime sleepiness

Treatments: Drugs such as dopamine agonists and eliminate caffeine-containing products

Periodic Limb Movement in Sleep

14

Patient’s report of his or her sleep pattern and sleep-related problems

Determine quality and quantity of sleep.

Review the number of nocturnal awakenings and length of time awake at night.

Typical bedtime rituals or practices

Daytime sleepiness or a strong desire to nap

Assess consumption of alcohol, caffeinated beverages, sedative-hypnotics, OTC drugs, and other practices before bedtime.

Components of the Sleep History

15

Sleep diary

Sleep laboratory

Epworth Sleepiness Scale (ESS)

Pittsburgh Sleep Quality Index

Further Assessment of Sleep

16

Stable schedules and bedtime routines, a sleep-friendly environment, avoidance of any substances that would interfere with sleep, regular exercise (but not immediately before trying to sleep), and stress reduction

Nonpharmacologic interventions: relaxation therapies, stimulus control therapy, and sleep restriction therapy and cognitive behavioral therapy

Drug therapy may be necessary for a short time no more than one or two weeks.

Sleep Hygiene

17

Routine daily activities, diversional activities, and physical exercise

Changes occur in the activities pursued by older adults as they age or experience acute or chronic illness.

Physical exercise has health-promoting benefits for all older adults.

Activity and Older Adults

18

Activities that once were accomplished with ease may require modified approaches or the assistance of others.

Modification of routines and use of assistive devices help maintain independence.

Family members, friends, or paid caregivers may help with shopping and other tasks.

Dependency in basic ADLs increases the risk of relocation to a long-term care facility or to the home of a family member.

Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs)

19

Important to maintain health, preserve the ability to perform ADLs, and improve the general quality of life

Prevents of heart disease, reduces elevated blood pressure and risk of osteoporosis, promotes appropriate weight and more restful sleep

Preserves mobility and reduces the risk of falls by promoting muscle strength and joint flexibility

Physical Exercise

20

Moderate-intensity aerobic exercise for 150 minutes a week

Drink water before and after exercise

Clothing should allow for easy movement and perspiration.

Athletic shoes should provide both support and protection.

Outdoor exercise should be avoided in extremely hot or extremely cold weather.

Stop exercising and seek help for chest pain or tightness, shortness of breath, dizziness or lightheadedness, or palpitations during exercise

Physical Exercise Tips

21

Retirement, relocation, and the loss of a spouse

Alzheimer’s disease, when it progresses, cognitive impairment increases, which adversely affects the ability to initiate and participate in routine daily activities

Older adult with advancing dementia also loses the ability to initiate diversional activities and to participate in activities that were once enjoyed.

Lifestyle Changes that
Affect Activity

22

Activities should be meaningful, have a purpose, and foster a sense of well-being for the participants.

Physical exercise is important for general physical well-being.

Exercise may reduce agitation or wandering.

Rhythmic movement of a rocking chair may reduce agitation.

Going for a walk may redirect the impulse to wander.

Activities that tap into the older adult’s past life experiences and interests may stimulate memory.

Activity and Alzheimer’s Disease and Other Dementias

23

Chapter 11

Safety

The leading cause of fatal and noninjuries in older adults

Results in higher rates of morbidity and mortality among those older than 75 because of the higher incidence of frailty and a limited physiologic reserve

Leading cause of hip fractures

Education is the cornerstone of fall prevention and management.

Falls

2

Older individuals may not perceive a slip that results in a fall to the floor to be an actual “fall”; rather it may be termed a slip, trip, or accident, but not a fall.

Anything that causes a person to unintentionally move from one level plane to another

Definition of Falling

3

Is a concept that holds negative connotations because it is associated with a decline, drop, or descent to a lower level

Involves several related variables and most likely is determined according to an individual perception of how serious the fall is in terms of daily living

The health care professional may equate a fall with a decline in patient health or function or a worsening of a patient’s condition

Meaning of Falling to Older Adults

4

Vision—depth perception, problems with glare

Hearing—decrease in directional hearing, hearing loss

Cardiovascular—orthostatic hypotension

Musculoskeletal—osteoarthritis, muscle weakness, reduction in steppage height, which may increase risk for tripping

Neurologic—slowed reaction time

Normal Age-Related Changes That Contribute to Falling

5

Is not determined solely on the basis of number and kind of diseases, but on how risk factors influence areas of mobility, transferring, and negotiating within the environment

Best determined by observation of mobility

Risk categorized according to intrinsic (illness or disease-related) or extrinsic (environmental) risk

Research has shown that the individual with frailty and physical functional limitations is at greatest risk for falling.

Fall Risk

6

Combined effect of normal age-related changes and concurrent disease

Relates to gait, balance, stability, and cognition

Intrinsic Fall Risk

7

Environmental hazards, both indoors and outdoors

Steps

Floor surfaces

Edges and curbs

Lighting

Grab rails

Extrinsic Fall Risk

8

Hip fractures, head trauma, and internal bleeding affect a small percentage of older individuals who fall.

High mortality rate associated with hip fractures

Physical restraints can increase risk and should never be used.

Injury by attempting to remove the restraints: strangulation and asphyxiation

Elevation of both side rails can cause falls from attempts to climb over side rails.

Risk for Serious Injury

9

Behavior modification requires older patients to recognize behaviors that are contributing to problem and then to make conscious attempts, whenever a behavior is performed, to change or alter it.

Teaching patients with osteoporosis the ways to incorporate calcium-rich foods in their diet on a daily basis, and about the risk factors for the development of osteoporosis

Identify and treat causes of delirium

Reducing the Risk for
Serious Injury

10

Isolated falling: one-time event that was most likely purely accidental

Cluster falls: observed among individuals with specific diseases who decompensate

Premonitory falls: produced by specific medical illnesses, e.g., new onset seizures

Prodromal falling: onset of frequent falling heralding an acute medical problem

Intentional falls: fall on purpose, possibly with a desire to do harm

Fall Classification

11

Physical injury ranges from trivial trauma—skin tears and sprains to serious injury-hip fractures, internal bleeding, or subdural hematomas.

Osteoporosis—serious injury

Psychological trauma like post fall trauma is influenced by to personality changes, depression, anxiety, and stress-related syndromes.

Fear of falling interferes with activity and fosters dependence

Fall Consequences

12

The nurse is caring for an older adult patient who was admitted for pneumonia. The nurse institutes fall precautions based on which of the following assessments? (Select all that apply.)

The patient has rheumatoid arthritis.

The patient fell at home last month.

The patient is hard of hearing.

The patient uses the call light frequently.

The patient is taking antihypertensives twice a day.

Quick Quiz!

13

ANS: B, C, D

Answer to Quick Quiz

14

History—the acronym SPLATT can help evaluate:

Symptoms at the time of the fall

Previous fall

Location of the fall

Activity at the time of the fall

Time of the fall

Trauma post fall

Physical exam—focused examination based on the patient’s presenting complaints, also sensory, cardiovascular, musculoskeletal, and neurologic systems

Evaluation After a Fall

15

Sternal nudge

Tinetti assessment tool for balance

The timed up and go (TUG)

Special Testing for Gait and Balance

16

Goals: identify the underlying cause, reduce the incidence of recurrent falls, and prevent serious injury

Fall diary

Bed or chair alarms

Video surveillance cameras

Safety belts in wheelchairs and the “lap buddy”

Injury epidemiology

Nursing Management of Falls

17

Examples of burn Injuries:

Burns, cigarette smoking, fireplace hazards, kitchen hazards, space heaters

Examples of nonburn Injuries:

Carbon monoxide poisoning, chemical injuries, cooling fans, food-borne illnesses

Safety and the Home Environment

18

Core body temperature of less than 95°F

Risk factors

Clinical manifestations—fatigue, apathy, confusion, lethargy, shivering, numbness, slurred speech, impaired coordination, and possible coma

Management—sponge baths with cool water, fans to circulate cool air, decreasing the room temperature, placing ice packs on the groin and axilla, and cooling blanket

Hypothermia

19

Core body temperature greater than 105°F

Risk factors

Clinical manifestations—anhidrosis, confusion to coma; hallucinations, combativeness, bizarre behaviors, and syncope

Management—passive external rewarming with blankets for mild; active core rewarming with IV fluids for moderate to severe

Hyperthermia

20

60% of those who suffered medical problems or died during Hurricane Katrina were frail older adults (AARP, 2013)

We Can Do Better; Lessons Learned for Protecting Older People in Disasters and Recommendations for Best Practices in the Management of Elderly Disaster Victims

Disasters

21

Storage of medications at home can become a safety and drug-effectiveness issue

Most drugs degrade when left in direct sunlight, with or without excessive heat

Appropriately dispose of all outdated prescriptions when new ones are written

Proper disposal of used wound dressings and needles or syringes

Storage of Medications and Health Care Supplies in the Home

22

Fear of crime reduces subjective well-being.

Neighborhood strategies to protect older adults living alone

Daily telephone calls to specific persons on a call list

Raising and lowering window shades or curtains at specific times of the day and evening, which will be monitored by a specific person

Mail carrier alerts when mail is not picked up daily from mailboxes of enrolled older persons

Living Alone

23

Maintaining independence includes the ability to travel to shopping centers and health care providers’ offices, to visit family and friends, and to participate in recreational activities.

A decline in an older adult’s ability to drive safely may result in the loss of driving privileges.

Driving evaluations are essential for older adults with suspected dementia.

Traffic sign identification test

Automobile Safety

24

Vertigo

Seizure disorders

Stroke sequelae

Macular degeneration or retinal hemorrhage

Unstable cardiac arrhythmias

Disorders That Adversely Affect
Driving Ability

25

A scale to rate the potential for abuse or neglect helps nursing personnel become aware of the incidence and prevalence.

Older persons with physical or mental frailties are more vulnerable to abuse and neglect than are independent older adults.

Need for assistance with basic ADLs may overstress the caregivers.

Stress and strain of caregiving tasks is often the cause for initial abuse or neglect.

Abuse and Neglect

26

Neglect

Psychological or emotional abuse

Financial abuse or exploitation

Physical abuse

Sexual abuse

Abandonment

In 90% of abuse and neglect cases, a family member is identified as the perpetrator.

Six Areas of Abuse or Neglect

27

Firearms are associated with high rates of suicide among older men and women.

Age group with the highest rate of successful suicide attempts with firearms is persons age 80 or older.

Dangers of firearms include the potential for accidental injury during weapon cleaning and handling.

Risk of a criminal entering a home and taking the weapon away from an older person with fatal consequences

Firearms

28

Chapter 12

Sexuality and Aging

1

Sexuality is an important part of health, general well-being, and quality of life.

Sexuality includes various types of intimate activity, as well as the sexual knowledge, beliefs, attitudes, and values of individuals.

Nurses play a key role in the assessment of changes related to aging, disabling medical conditions and drugs, and can intervene at an early point to enhance sexuality.

Older Adults’ Sexual Needs

2

“Sexuality is a central aspect of being human throughout life and encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy, and reproduction … is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviors, practices, roles, and relationships …. Sexuality is influenced by the interaction of biologic, psychological, social, economic, political, cultural, ethical, legal, historical, religious, and spiritual factors”

The World Health Organization’s
View on Sexuality

3

Despite evidence supporting not only the need for, but the importance of, sexual expression in older adults, health care professionals carry out few interventions to facilitate expressions of sexuality.

Benefits of sexual expression include increased happiness, energy, and relaxation, decreased pain, improved cardiovascular health, decreased depressive symptoms, increased self-esteem, and improved satisfaction with relationships.

Sexual Expression

4

Society regards sexuality in older adults as undignified.

Nurses often share society’s ageist beliefs about the asexuality of older adults, which may lead to nurses discouraging sexual activity.

Older adults may face difficulties with sexual expression.

Because of discomfort, myths, ageism, and lack of training in sexual health, problems with newly developed or chronic sexual dysfunction are ignored.

Barriers to Sexual Expression

5

The orgasm response changes in both sexes.

Reduced availability of sex hormones results in less rapid and less extreme vascular responses to sexual arousal.

Erectile dysfunction

Sexual dysfunction in older women encompasses loss of sexual desire, problems with arousal, inability to achieve orgasm, and painful intercourse.

Normal Changes of the
Aging Sexual Response

6

Changes in the genitourinary tract related to menopause

Genital symptoms include: dryness, burning, and irritation

Sexual symptoms include: decreased lubrication, thinning of the vaginal wall, decreased elasticity and vaginal rugae, leading to pain, and bleeding during intercourse

Urinary symptoms include: urgency, dysuria, and recurrent urinary tract infections

Genitourinary Syndrome of Menopause

7

Illness, surgery, and medication

Human immunodeficiency virus—45% of age 55 years and older account for adults with HIV; are likely to be diagnosed late in disease, experience progression more quickly, and die sooner after diagnosis than younger adults

Malignancies—breast, prostate, colon cancer

Dementia—changes in cognition and judgment occur, can cause either a decrease in sexuality, or sexual disinhibition

Conditions Affecting
Sexual Responses

8

These adults long for physical closeness and seek out physical touch but their intentions may be misinterpreted as sexual in nature

May express sexually disinhibited behaviors, which include sexually explicit or suggestive language, exhibitionism, repeated attempts to have sex or aggressive sexual demands

Nonpharmacological interventions should be used to diffuse the situation

Pharmacological interventions may become necessary when the behaviors become harmful or detrimental to safe care.

Dementia

9

Sexual dysfunction may signal other psychosocial disorders such as depression, delirium, and dementia.

Substance abuse including smoking, alcohol, and illicit or recreational drug use, is often associated with sexual dysfunction

Health care professionals working with cognitively impaired older adults need to determine whether the individual is consenting to a sexual activity.

Environmental and Psychosocial Barriers to Sexual Practice

10

LGBT face many health disparities, including victimization, psychological distress, disability, discrimination, and lack of access to appropriate health services.

Despite stereotypes, it is important for nurses to recognize that LGBT as acceptable expressions of sexuality for both men and women.

LGBT may be hiding their sexual preference and gender identity from family so no information about the sexual orientation should be shared with a patient’s family unless permission has been given.

Lesbian, Gay, Bisexual, and Transgender

11

Obtain sexual history

Assessment—PLISSIT

Review medications and medical conditions that may contribute to sexual dysfunction.

Physical assessment of the genitalia

Laboratory tests—check hormone levels

Obtain information on sexual preferences

Can you give five Nursing Diagnoses for sexual health?

Sexual Health Nursing Management: Assessment and Diagnosis

12

203656 (BB) – Please note that in other chapters, for question “Can you name … nursing diagnose …”, the answer has been listed in the notes part. Please provide the same in this slide.

Permission

Limited information

Specific suggestions

Intensive therapy

PLISSIT

13

May hinder a patients’ decision making abilities

Meet with both patients to discuss their intentions and expectations regarding the sexual relationship—may reveal whether one patient is being coerced into the relationship or is not mentally competent to decide to enter such a relationship

Perform a cognitive assessment—Montreal Cognitive Assessment.

Cognitive Impairment

14

The patient will:

Attain a satisfactory level of sexual activity as evidenced by resumption of sexual activity at a level acceptable to the patient.

Verbalizes their sexual concerns and discusses them with their significant other.

Explore various sexual activities and practices to attain sexual satisfaction.

Verbalize their feelings about sexual performance.

Sexual Health Nursing Management: Planning and Expected Outcomes

15

Provide information, education, and direction to assist patients in creating and sustaining intimate relationships.

Offer teaching and reassurance that some changes are a normal part of aging.

Teach alternative methods of intimacy in the form of touch.

Encourage low-risk behaviors.

Manage difficult behaviors of cognitively impaired patients.

Sexual Health Nursing Management: Interventions

16

Make proper arrangements for privacy during older adults’ sexual experiences.

Provide room with a pleasant environment, which may be reserved by older adults for private visits with a spouse or partner.

Patient safety should be maintained, call lights easily accessible; side rails on the bed used if necessary; room should be situated so that the nursing staff is aware of when it is in use.

Provide staff education about the sexuality and intimacy of older adults.

Interventions in Acute and
Long-term Care Facilities

17

Based on patient achievement of the established expected outcomes

Older adults may attain a satisfying level of sexual activity that is compatible with functional capacity.

When sexual functioning cannot be restored, alternatives should be explored.

Proper documentation is important to communicate the interventions and progress toward meeting the expected outcomes.

Sexual Health Nursing Management: Evaluation

18

The nurse is working in a skilled nursing facility. An older married couple are patients at the facility. The nurse enters the female patient’s room and sees the male patient making sexual advances toward his wife. The nurse’s best action would be which of the following?

A. Close the door to allow them privacy, and place a do-not-enter sign on the door.

B. Suggest he go back to his room until visiting hours are over and the other patients are sleeping.

C. Inform the couple that this behavior is not allowed and is offensive to the staff.

D. Ask the female patient if she is comfortable with the situation; leave the room if she says yes.

Quick Quiz!

19

ANS: D

Answer to Quick Quiz

20

Chapter 9

Nutrition

Food means life, comfort, and security.

Older adults living in the community may suffer from loneliness and depression, leading to weight gain or loss, and ultimately malnutrition.

Food

2

Social factors include isolation, loneliness, poverty, dependency, lack of caregivers, and transportation.

Psychological factors include depression, anxiety, and dementia.

Weight loss, psychotropic drugs = anorexia, apraxia

Biological factors include hypermetabolism, anorexia, swallowing difficulty, or malabsorption.

Stroke, tremors, arthritis, infection, COPD, Parkinson’s

Nutritional Risks in Older Adults

3

Several medications associated with poor appetite and weight loss

Interactions between nutrients and medicines may affect metabolism, absorption, digestion, or excretion of drugs.

Carefully assess all medications including over-the-counter drugs for drug–drug and drug–nutrient interactions.

Drug Nutrient Interactions

4

Nutritional interventions that do not take into account the social, cultural, and emotional aspects of food are rarely effective because few individuals “eat to survive”; most of us “survive to eat.”

4

Three main forms

Isotonic dehydration—results from the loss of sodium and water, as during a gastrointestinal illness

Hypertonic dehydration—results when water losses exceed sodium losses. Most common, from fever or limited fluid intake

Hypotonic dehydration—may occur with diuretic use when sodium loss is higher than water loss

Dehydration

5

Micronutrients—vitamin D, calcium, and vitamin B12 are commonly found deficient in older adults

Vitamin D deficiency—cancer progression, osteoporosis, and fractures

Vitamin B12 deficiency—pernicious anemia, bone health, and cognitive decline

Supplementation might be necessary.

Micronutrient Deficiency

6

Sarcopenia is defined as “the decline in skeletal muscle mass that can result from physical inactivity, disuse of muscles, reduced levels of growth hormone and testosterone, neuromuscular changes, insufficient dietary protein and impaired protein metabolism.”

Can occur after long hospitalization

Cachexia is characterized by a loss of fat and muscle mass accompanied with anorexia.

Terminal cancer or/and stage renal disease

Malnutrition

7

Oral health is a strong predictor or measure of quality of life.

Xerostomia, or dry mouth, is one of the most common causes of poor food intake.

Drug induced can lead to dental carries.

Older adults with cognitive impairment are at increased risk for dental caries, oral infections, and periodontal disease.

Oral Health

8

Nutritional screening: abbreviated assessment of nutritional risk factors determining which clients need a more comprehensive assessment and nutritional interventions

Nutritional assessment: comprehensive evaluation of client’s nutritional status

Demographic and psychosocial data, medical history, dietary history, anthropometrics, medications and laboratory values, and physical assessment

Nutritional Screening and Assessment

9

Clients at nutritional risk require a more specific evaluation of their dietary intake patterns.

Number of meals and snacks per day; chewing or swallowing difficulties; gastrointestinal problems or symptoms that affect eating; oral health and denture use; history of diseases or surgery; activity level; use of medications; appetite; need for assistance with meals and meal preparation; and food preferences, allergies, and aversions

Food recall

Diet History

10

Height and weight

Triceps skin fold and mid-upper arm muscle circumference

Dual-energy x-ray absorptiometry (DXA)

Anthropometrics

11

Serum albumin

Levels below 3.5 g/dL may indicate some degree of malnutrition.

Transferrin

< 200 mg/dL indicate mild-to-moderate depletion.

<100 mg/dL indicate severe depletion.

Prealbumin

Levels from 15 to 5 mg/dL—mild-to-moderate protein depletion

<5 mg/dL—reflective of severe protein depletion

Laboratory Values

12

Albumin has a half-life of about 21 days, so it is not always reflective of current nutritional status.

Transferrin

Carrier protein for iron and has half-life of 8–10 days.

Prealbumin

Half-life of 2–3 days

Sensitive to sudden demands on protein synthesis

12

MyPlate method

Dietary guidelines 2016

Eat a variety of nutrient-dense foods and manage portion sizes

Shift current food and drink choices to healthier alternatives

Maintain a healthy diet throughout your life

Limit caloric intake from added sugars and saturated fats, and reduce intake of sodium

Support others in healthy eating

Components of a Healthy Diet

13

A problem that often affects nutritional status

Cerebrovascular accident, oral or neck cancer treatment, or a neuromuscular or neurologic disorder

Early detection, screening, evaluation, and treatment

Modification of foods and fluids

Dysphagia

14

Your patient is not eating well, and you have consulted a dietician to see the patient. Which of the patient’s assessment and laboratory findings have you most concerned? (Select all that apply.)

The patient has COPD and usually does not finish all her food on the tray.

The patient wears dentures and cares for them daily.

The patient is widowed and does not seem to have visitors during meal time.

The patient’s serum albumin level is 4 g/dL.

The patient’s transferrin level is 188 mg/dL.

The patient’s prealbumin level is 10 mg/dL.

Quick Quiz!

15

ANS: A, C, E, F

Answer to Quick Quiz

16

Enteral feeding tubes

NG, PEG, or PEJ tubes

Several different types of enteral formulas available

Parenteral nutrition

Indicated when GI tract cannot be used

Administered via vascular access device-central venous catheter, tunneled catheter, peripherally inserted central catheter, or implanted port

Solution: dextrose, amino acids, vitamins, minerals, electrolytes, trace elements, water, and lipids

Specialized Nutritional Support

17

Chapter 13

Pain

Is a common experience for many older adults

Is not an expectation of aging

Pain is under recognized, highly prevalent, and undertreated among older adults.

Degenerative changes, musculoskeletal changes, and pathologic and comorbid conditions from disease or injury lead to pain in older adults.

Pain

2

Pain is “Whatever the experiencing person says it is, existing whenever he or she says it does” McCaffery (2000)

“A subjective, personal, unpleasant experience involving sensations and perceptions that may or may not relate to bodily or tissue damage” Aronoff (2002)

Pain is individual and may be very different for different persons with the same disease or injury.

Defining Pain

3

Acute pain: rapid onset and relatively short duration and a sign of a new health problem requiring diagnosis and analgesia

Treat underlying cause—short-term analgesia

Chronic or persistent pain: continues after healing or is not amenable to a cure; usually has no autonomic signs and is associated with longstanding functional and psychologic impairment

Pain Classification

4

Somatic pain—well defined. It may be aggravated by movement, due to articular disorders, deep and aching, may be sharp

Visceral pain—caused by organ stretch, inflammation or ischemia, diffuse and not well defined, may be referred, intense pressure, a deep squeeze, or dullness

Nociceptive Pain

5

Results from a pathophysiologic dysfunctional process involving the peripheral or central nervous system

Do not respond as predictably to analgesic therapy as nociceptive types of pain

Includes paresthesias (the tingling, pins and needles sensation), burning, lancinating (stabbing, cutting, shooting)

Responds to drugs such as tricyclic antidepressants (TCAs), anticonvulsants, or antiarrhythmic drugs

Neuropathic Pain

6

Mixed or unspecified pain has unknown mechanisms, treatment is unpredictable requiring more trials of different approaches.

Other types of pain can be caused by conditions such as conversion reaction or psychological disorders, may benefit from specific psychiatric treatments.

Mixed or Unspecified and
Other Types of Pain

7

50% of community-dwelling older adults experience significant pain problems.

70%–80% of nursing home residents have substantial pain that is undertreated.

Older adults commonly report less pain because:

Do not want to be complainers

Fear more tests and medicines

Fear losing their independence

Scope of the Problem of Pain

8

Depression, anxiety, decreased socialization, sleep disturbance, decreased or impaired ambulation, prolonged recovery periods, increased use of health care resources, health care use and costs, and premature death

Decreased ambulation, impaired posture, sleep disturbance, anxiety, and impaired appetite in nursing home residents

Incontinence and constipation are also related to unrelieved pain.

Consequences of Unrelieved Pain

9

Listening to older adults

Relief from pain

Control of chronic disease conditions causing pain

Maintenance of mobility and functional status

Promotion of self-care and maximum independence

Improved quality of life

Goals for Pain Management

10

Three components of nervous system cause the sensation and perception of pain.

Afferent pathways (reception)

Nociceptors found on the skin

Central nervous system (perception)

When pain stimulus reaches the central nervous system

Efferent pathways (reaction)

Interpretation is relayed back through peripheral nervous system (efferent) pathways.

Pathophysiology of Pain

11

Belief that pain is a natural occurrence of aging, and chronic disease

Underreporting of pain by older adults

Inadequate access to diagnostic services

The nurse’s lack of knowledge regarding adequate pain assessment

Barriers to Effective Pain Management

12

They may fear the meaning of pain and its implications of worsening disease and possible death.

Patients experiencing cancer-related pain may believe it is a natural outcome of cancer and cannot be relieved.

Barriers to Effective Pain Management in Older Adults With Cancer

13

Asses on a scale of 1–10 scale

Breathing

Negative vocalization

Facial expression

Body language

Consolability

Persons With Dementia

14

Assessment is essential in differentiating acute life-threatening pain from longstanding chronic pain.

Includes thorough history and physical examination

Use the general principles on pain assessment from American Geriatrics Society (AGS) Panel on Persistent Pain in Older Persons (2002)

Be aware of cultural differences related to pain management

Pain Assessment

15

Numeric pain rating scales

Visual analog scales

Descriptive pain intensity scales

Pain diaries

Pain logs

A patient’s report of pain should also be evaluated for its intensity and the amount of distress it causes.

Pain Assessment Tools

16

Address: the onset, location, duration, intensity, characteristics, aggravating and alleviating factors, and self-treatment or other prescribed treatments that either helped or did not help

P, Q, R, S, T, U mnemonic

Comprehensive examination of the musculoskeletal and nervous systems

Evaluate for functional impairment

History and Physical Examination

17

Evaluation of quality of life as pain influences all dimensions of an individual’s quality of life.

Evaluation for depression since high incidence of depression associated with chronic pain

Geriatric depression scale

Additional Evaluations

18

The nurse has just started a hospital job where the majority of her patients are older adults. It is important that the nurse remember which of the following regarding older adults and pain? (Select all that apply.)

They may have several chronic illnesses that cause them pain.

They tend to overuse pain medication.

They believe pain is natural outcome of cancer.

When they are confused, they may not respond pain in the usual way.

They do not understand pain scales.

Quick Quiz!

19

ANS: A, C, D

Answer to Quick Quiz

20

Medications play an important role.

Nurses must be knowledgeable of the physiologic changes of aging that can alter drug absorption, metabolism, and excretion in the older adult.

Changes, especially those in liver and renal function, can increase the risk of accumulation of lipid-soluble drugs.

Analgesic drugs—classified as nonopioid analgesics and opioid analgesics

Pharmacologic Treatment

21

Nonopioids

Mild opioids (codeine)

Strong opioids (morphine)

Adjuvant drugs for anxiety or increased pain

Medications should be given around the clock.

Treating Cancer Pain

22

First-line approach to pain management

Acetaminophen (Tylenol), ibuprofen (Motrin, Advil), and naproxen (Naprosyn, Aleve)

Block pain by inhibiting pain reception at local level

Acetaminophen is drug of choice for musculoskeletal pain; does not affect platelet levels.

Maximum dosage is 3,000 mg/24 hours.

Nonopioid Analgesics

23

Effective for treating mild to moderate arthritic pain and other inflammatory disorders

Have been associated with stomach ulcers, renal insufficiency, and a tendency to bleed

The most common complaint associated with NSAIDs is indigestion, which may be reduced with antacid use or food consumption.

Avoided in high doses, for long periods, in presence of abnormal renal function, history of ulcer disease, or bleeding

Nonsteroidal Antiinflammatory Drug (NSAID)

24

Mild to moderate pain poorly tolerated or inadequately managed with mild analgesic, consider using an opioid analgesic

Start low, go slow

Problems with opioids usually involve those with long half-lives.

Moderate to severe pain can be relieved with hydrocodone, oxycodone, hydromorphone, oxymorphone, or immediate-release morphine.

Opioid Analgesics

25

Nausea, vomiting, constipation, and urinary retention

Older adults are more sensitive to sedation and respiratory depression especially opioid naïve.

Never give fentanyl patch to opioid naïve.

Constipation is of particular concern in older patients because many of them have preexisting bowel conditions so start on a bowel program when initiating opioid treatments.

Opioid Analgesic Side Effects

26

Medications without intrinsic analgesic properties

Anticonvulsants, antidepressants, and some sedatives

Anticonvulsants help control painful conditions: postherpetic neuralgia, diabetic neuropathy, and phantom limb pain.

Alter or modulate the perception of pain

Can be used alone or with other pain medications

Adjuvant Medications

27

Describe products and practices that are used in addition to mainstream medical practices

Natural products: include herbals and botanicals, as well as vitamins and minerals

Mind and body practices: include acupuncture, massage therapy, meditation, movement therapies, relaxation techniques, spinal manipulation, tai chi, healing touch, and yoga

Complementary and Alternative Medicine (CAM)

28

Heat and cold

Visualization or imagery

Progressive relaxation

Distraction

Exercise

Peripheral nerve

Music therapy

Hypnosis

Education

Other Therapies

29

Patients vary greatly in their medication requirements, choices of nonpharmacologic interventions, and prior pain experiences.

Patients and families should be involved in the plan.

Individualized Planning

30

Pathological conditions in older adults

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