NCLEX: Gerontologic care

Gerontologic care: Male reproductive system

Focus topic: Gerontologic care

In elderly men, reduced testosterone production may cause a decline in libido, atrophy and softening of the testes, and decreased sperm production.
Normally, the prostate gland enlarges with age, while its secretions diminish. Seminal fluid decreases in volume and viscosity.

Still sexual

During intercourse, elderly men experience slower and weaker physiologic reactions. However, these changes don’t necessarily weaken the sex drive or reduce sexual satisfaction.

Gerontologic care: Musculoskeletal system

Focus topic: Gerontologic care

Decreasing height is the most apparent age-related musculoskeletal change. This decrease results from exaggerated spinal curvatures and narrowing intervertebral spaces, which shorten the trunk and make the arms appear relatively long.
Other musculoskeletal changes include:
• decreased bone mass
• reduced muscle mass, which may lead to muscle weakness
• diminished collagen formation, which causes loss of resilience and elasticity in joints and supporting structures
• greater viscosity of synovial fluid
• increased fibrosis of synovial membranes.

Walking woes

An older adult may have difficulty performing tandem walking (walking heel-to-toe in a straight line). Also, he may take shorter steps and use a wider leg stance to achieve better balance and a more stable weight distribution.

Gerontologic care: Nervous system

Focus topic: Gerontologic care

Aging affects the nervous system in many ways. Neurons in the central and peripheral nervous systems undergo degenerative changes. Nerve transmission slows, causing the elderly adult to react more sluggishly to external stimuli.

Brain cell drain

After about age 50, the brain loses cells at a rate of about 1% per year. However, clinical effects usually aren’t noticeable until aging is more advanced.

Other neurologic changes
Here are other effects of age on the nervous system:
• The hypothalamus becomes less effective at regulating body temperature.
• The corneal reflex becomes slower, so the lids close more slowly in reaction to corneal irritation.
• The pain threshold increases.
• Certain sleep stages (including rapid-eye-movement sleep) shorten.

System overlap

When testing an elderly patient’s nervous system, keep in mind that neurologic changes stemming from alterations in other body systems may affect assessment findings. For instance, sensory receptor changes may lead to hearing and vision loss, cerebrovascular dysfunction, and mental status changes induced by medications. Other factors that can influence an elderly patient’s test results include fatigue, lack of sleep, depression, hyperactivity, fear, and anxiety. The patient may seem disinterested or preoccupied or he may be slow to respond.

Gerontologic care: Endocrine system

Focus topic: Gerontologic care

A common—and important—endocrine change in elderly adults is a decreased ability to tolerate stress. The most serious sign of a diminished stress response is altered glucose metabolism.

Stress and sugar spikes

Normally, fasting blood glucose levels don’t differ significantly in young and older adults. However, in an older adult, stress stimulates a rise in blood glucose that lasts longer than it does in a younger adult. In part, this stems from decreased insulin secretion and reduced responsiveness of insulin receptors. Approximately 25% of older people develop diabetes.

Thyroid slowdown

The thyroid hormones triiodothyronine and thyroxine decrease by 25% in older adults. Ordinarily, the remaining secretion of thyroid hormones is adequate for homeostasis. However, the basal metabolic rate and oxygen consumption slow.

Menstrual finale

During menopause, ovarian senescence causes permanent cessation of menstrual activity. Although changes in endocrine function during menopause vary from one woman to the next, estrogen and progesterone levels normally diminish and follicle-stimulating hormone production increases.
Estrogen deficiency in elderly women is linked to coronary artery disease and osteoporosis. In both men and women, other normal variations in endocrine function include a 50% decline in serum aldosterone levels and a 25% decrease in cortisol secretion rate.

Gerontologic care: Hematologic and immune systems

Focus topic: Gerontologic care

Total and differential white blood cell (WBC) counts don’t change significantly with age. However, after age 65, some people have a slight decrease in the range of normal WBC counts. When this happens, B cell and total lymphocyte counts decrease and T cells decrease in number and become less effective.

Me, myself, and nonself

Immune function starts to decline at sexual maturity and continues to diminish with age. The incidence of autoimmune disease rises as the immune system starts to lose the ability to differentiate between self and nonself.
The cancer incidence increases, too, as the immune system grows less proficient at recognizing and destroying mutant cells. Decreased antibody response in elderly adults heightens susceptibility to infection. Tonsillar atrophy and lymphadenopathy are common.

Gerontologic care: Assessment

Focus topic: Gerontologic care

Comprehensive health assessment of the older adult focuses on medical history and current health status, including a review of body systems and an evaluation of the patient’s dietary regimen and ability to function. Besides establishing the patient’s health status, the information you obtain during assessment helps you evaluate improvements or declines in his condition over time and helps determine whether he needs support services.

Gerontologic care: Health history

Focus topic: Gerontologic care

The information you elicit during the health history and interview alerts you to key areas to focus on during the physical examination. To begin the history, establish the patient’s well-being as your primary concern. Talking with him about health concerns promotes his health awareness, helps identify knowledge deficits, and allows you to launch your patient teaching.

Gerontologic care

Move along methodically

Because the patient may overlook some important health information, be sure to interview him methodically. When necessary, gather additional or corroborating information from his family or friends.

Current health status
Begin with the patient’s current health status. Ask him to describe his health, and record his responses using his own words.
Next, record the reason he’s seeking treatment (chief complaint). Ask him about current medication use and treatments, his diet, and any devices he uses (such as a cane, walker, or hearing aid).
If he seems confused or shows signs or symptoms of dementia, consider asking his permission to include a spouse, child, or significant other in the interview.

Medical history
During the medical history, obtain an overview of the patient’s general health status, a history of his adult illnesses, a record of past hospitalizations, frequency of practitioner visits, and previous use of drugs and other treatments and their purpose.

Review of body systems
When reviewing an older adult’s body systems, consider the physiologic changes normally associated with aging. Also, keep in mind that older adults commonly have atypical disease presentations. For example, subtle changes in appetite and mental status may be the only signs and symptoms of certain disorders.

Organized assessment

Assess specific body areas and systems using either the head-to-toe approach or the major body system approach. Both methods provide a systematic and organized framework, so choose the one that works best for you.

Gerontologic care: Physical examination

Focus topic: Gerontologic care

During the physical examination, use inspection, palpation, percussion, and auscultation to gather objective data that help validate the subjective data obtained from the health history.

General survey
Begin the physical examination with a general head-to-toe observation to gain an overall impression of your patient’s status. Be sure to observe:
• overall appearance, including body build, skin, hygiene, and grooming
• general mobility status
• level of consciousness (LOC), affect, and mood
• overt signs of distress.
Then take the patient’s vital signs. Keep in mind that in an older adult, normal body temperature ranges from 96º to 98.6º F (35.6º to 37º C).

Skin
Inspect the skin on the patient’s scalp, head, neck, trunk, and limbs. Be sure to note its color, temperature, texture, tone, turgor, thickness, and moisture. Remember that areas such as the knees and elbows may look a bit darker because of sun exposure and that calloused areas may look yellow.

Turgor testing

Focus topic: Gerontologic care

When assessing skin turgor, keep in mind that turgor may not reliably reflect hydration in older people, who have less subcutaneous tissue. For more accurate results, check turgor by gently pinching the subcutaneous tissue of the forehead or over the xiphoid process, and then watching for a quick return to baseline.

Skin scrutiny

Focus topic: Gerontologic care

Inspect the skin for tears, lacerations, scars, lesions, and ulcerations. Look for early signs of pressure ulcers such as local redness over pressure sites.
Stay alert for common benign skin lesions found in older adults; these must be differentiated from precancerous or malignant lesions. Note lesion size, distribution pattern, shape, color, consistency, and borders. Also, ask about the lesion’s onset. Any suspicious lesion warrants further evaluation.

Hair and nails
Inspect and palpate the patient’s hair, noting its color, quantity, distribution, and texture (fine, silky, or coarse). Know that hair thinning and sparseness are common around the axillae and symphysis pubis.

Nail ailments worth noting

Focus topic: Gerontologic care

Inspect fingernails and toenails, noting their color, shape, thickness, and capillary refill as well as the presence of any lesions. Some distortion of the normally flat or slightly curved nail surface is normal with aging, but other changes in color, shape, or angle may indicate a pathologic condition.

Head and face
Inspect the patient’s head, noting its size, contour, and symmetry. Skull size and shape don’t normally change with age. Soft-tissue swelling or cranial bulging may indicate recent head trauma. Palpate the skull, noting tenderness, masses, or lesions. Localized cranial enlargement requires further evaluation.

Reading faces

Focus topic: Gerontologic care

Inspect the face and neck for skin color and proportion. Skin color should be evenly distributed. Facial features should be proportionate to head size. Also observe the patient’s facial expression and movements.

Nose and mouth
Examine the external portion of the patient’s nose, noting any asymmetry or abnormality such as a structural deformity. Inspect the internal mucosa, noting its color and any discharge, swelling, bleeding, or lesions. The area should be pink and moist, with clear mucus and no crusting or lesions. Palpate the frontal and maxillary sinuses for tenderness, which should be absent.

Oral observations

Focus topic: Gerontologic care

Inspect the mouth, starting with the lips. Note their color, symmetry, and hydration status as well as any lesions or ulcers. Dry, parched lips indicate dehydration.
Note whether the patient wears a dental appliance. Inspect his mouth with the appliance in place, noting its fit and observing for sores or abscesses resulting from friction.
Then inspect the oral mucosa, noting color, texture, hydration status, and any exudate. The mucosa and gums should be pink, smooth, and moist— although in a dark-skinned person, the mucosa normally may be slightly bluish. Palpate the oral mucosa for lesions and nodules, noting tenderness, pain, or bleeding. Inspect the gums for color, inflammation, lesions, and bleeding. They should be pink and moist. If your patient has his natural teeth, note their number and condition.

Tales of the tongue

Focus topic: Gerontologic care

Next, observe tongue color, size, texture, and coating. The tongue is normally pink to red, smooth, and free from involuntary movement. Assess tongue position; deviation to one side suggests a neurologic disorder.
Observe the pharynx for signs of inflammation, discoloration, exudate, and lesions. It should be pink to pale pink, without discharge or lesions.

Eyes
When examining an older adult’s eyes, keep in mind that ocular signs of aging can affect the appearance of the entire eye. Also, know that age-induced fatty tissue loss may cause the eyes to sit deeper in the bony orbits.

Lids and lacrimation

Focus topic: Gerontologic care

Compare eyelid color to facial skin color; the lid should be free from redness and other color changes. Check for lesions and edema, and note the direction of the eyelashes. Determine whether the upper eyelid partially or completely covers the pupil—which indicates ptosis, an abnormal finding. Inspect the lacrimal apparatus, noting discharge, redness, edema, excessive tearing, or tenderness. Examine the sclera and conjunctiva; the sclera should appear creamy white.

Pointers on pupils

Focus topic: Gerontologic care

Next, inspect the pupils, noting their size, shape, and reaction to light. Observe the iris, noting any margin aberrations. You may see bilateral irregular iris pigmentation, with the normal pigment replaced by a pale brown color.

Acuity analysis

Focus topic: Gerontologic care

Test the patient’s visual acuity with and without corrective lenses, and note differences. Perform an ophthalmoscopic examination to inspect internal eye structures.

Ears
Inspect the auricle of the ears, noting color and temperature changes, discharge, or lesions. Palpate the auricle for tenderness. Inspect internal ear structures with an otoscope. Examine the external canal and tympanic membrane, and observe for the light reflex. Note lesions, bulging of the tympanic membrane, cerumen (earwax) buildup, or (in a male) hair growth.

Can you hear me now?

To detect hearing loss early, perform the Weber and Rinne tuning fork tests. Also, evaluate the patient’s ability to hear and understand speech, in case you need to recommend rehabilitative therapy. If the patient wears a hearing aid, inspect it closely for proper functioning.

Neck
Inspect the patient’s neck, noting scars, masses, or asymmetry. Gently palpate any masses, noting their consistency, size, shape, mobility, and tenderness. Repeat this inspection for the lymph nodes. Check the trachea for alignment. Normally, the trachea is midline at the suprasternal notch. Note any displacement or masses.

Spying on the thyroid

Inspect the thyroid gland while your patient sips water. Note any masses or bulging. Normally, the thyroid can’t be seen or palpated.

Chest and respiratory system
Inspect the shape and symmetry of the patient’s chest, both anteriorly and posteriorly. Note the anteroposterior-to-lateral diameter. During respirations, listen for inspiratory or expiratory wheezing, which may be audible from the oral airways.

Palpate the anterior and posterior chest for tenderness, masses, and lumps. Assess diaphragmatic excursion. Palpate the anterior and posterior chest symmetrically for tactile fremitus. Usually, fremitus is most evident near the tracheal bifurcation.

A percussion discussion

Percuss the patient’s lung fields anteriorly and posteriorly from the bases to apices. Be sure to percuss in a symmetrical pattern for comparison. Normal lung fields sound resonant. Bony prominences, organs, or consolidated tissue sound dull.
Next, auscultate from the lung bases to the apices, anteriorly and posteriorly. Ask the patient to take some deep breaths, in and out, with his mouth open. You may hear diminished sounds at the lung bases if some of the airways are closed. Inspiration is significantly more audible than expiration.

Cardiovascular system
Inspect and palpate the point of maximal impulse (PMI, or apical pulse), normally located in the fourth or fifth intercostal space just medial to the midclavicular line. In an older adult, the PMI may be displaced downward to the left. Using the ball of your hand, palpate over the aortic, pulmonic, and mitral areas for thrills, heaves, or vibrations. You may detect a palpable thrill in a patient with valvular heart disease.

Heart sound symphony

Auscultate the heart over the aortic, pulmonic, tricuspid, and mitral areas and Erb’s point, listening for the first and second heart sounds (S1 and S2) over each area. Also listen for extra diastolic heart sounds, or third and fourth heart sounds (S3 and S4). In an older adult, S3 heard between S1 and S2 (usually at the lower sternal border) isn’t a reliable indicator of heart failure. Instead, it may be physiologic or occur in response to an increased diastolic flow. You may hear S4 after S2 and before S1—most audibly over the heart’s apex.

Vessel investigation

Next, assess blood vessels of the patient’s head, neck, trunk, and extremities. Palpate the carotid arteries one at a time, pressing lightly so you don’t obliterate the carotid pulse. Note the rate, rhythm, strength, and equality of both pulses. Auscultate each carotid artery for bruits—humming or high-pitched sounds that may represent narrowing of the arterial lumen. Evaluate for jugular vein distention. Identify the level of venous pulsation and measure its height relative to the sternal angle. A height exceeding 11/8 (3 cm) is considered abnormal and may indicate right-sided heart failure. Palpate the peripheral arteries, noting the rate, rhythm, strength, and equality of pulses and checking for bruits. In an older adult, expect the arteries to be tortuous, kinked and, possibly, stiffer. However, pulses should be symmetrical in strength.

Limb look-see

When inspecting the legs, note their color and temperature and check for edema, varicosities, and trophic changes of the toes. Using the ball of your hand, assess the temperature of the arms and legs, which should be equal bilaterally. Thrombosis is usually associated with a sensation of heat, although this response may be reduced in an older adult.

Edema exploration

Finally, check for edema, which is best assessed over bony prominences or the sacrum. Typically, edema is more pronounced in the most dependent body areas. Determine if the edema is pitting or nonpitting, and grade the degree of edema.

GI system
When examining the GI system, be aware that older adults are more likely to have abdominal distention and less likely to have abdominal rigidity than younger adults. Inspect the abdomen, noting its shape and symmetry and any scars, masses, pulsations, distention, or striae. Describe the abdomen as obese, scaphoid, or distended. Auscultate all four abdominal quadrants for bowel sounds. Listen over the abdominal aorta for bruits. Next, percuss the abdomen to determine the presence of air or fluid, assess liver size, and check for bladder distention. Air in the large bowel sounds tympanic, whereas fluid sounds dull.

Palpation implications

Palpate the belly, noting masses or tenderness on light or deep palpation. Watch for peritoneal signs, such as rigidity or rebound tenderness. Masses in the lower quadrants may be impacted stool. Try to palpate the liver; normally it isn’t palpable.

Genitourinary system
When you assess the patient’s genitourinary system, use the same basic technique as you would in a younger patient. Note that pubic hair becomes sparse and gray with age. Normally, the testes of an older male are slightly smaller than adult size. However, they should be equal, smooth, soft, and freely movable, without nodules.

Musculoskeletal system
Assessing the musculoskeletal system helps determine the older adult’s overall ability to function. Limitations in range of motion (ROM), difficulty in ambulation, and diffuse or localized joint pain can be detected easily during the physical examination. Stay alert for signs and symptoms of motor and sensory dysfunction, such as weakness, spasticity, tremors, rigidity, and sensory disturbances.

Rating the gait

Observe the patient’s walk, noting his gait and posture. Gait reflects integration of reflexes as well as motor function. Assess static balance and station by gently pushing on his shoulders while he’s standing.
Then observe the patient’s tandem (heel-to-toe) walking, watching for exaggerated ataxia (coordination difficulties) and observing the position of his head and neck relative to the shoulders and legs.
To evaluate posture and balance, elicit Romberg’s sign by noting whether the patient sways or falls when standing with his feet close together and eyes closed. Swaying indicates a positive Romberg’s sign.

Judging joints

Inspect the joints of the hands, wrists, elbows, shoulders, neck, hips, knees, and ankles. Note any joint enlargement, swelling, tenderness, crepitus, temperature changes, or deformities.

Following the feet

Assess the feet for common deformities, such as:
• hallux valgus—angulation of the great toe away from the midline or toward the other toes
• metatarsal (forefoot) prolapse
• hammer toe—bending of the second, third, or fourth toe at the middle joint.

Taking measure of muscles

Inspect each muscle group for atrophy, fasciculations, involuntary movements, and tremor. Move the joints through passive ROM exercises, and palpate the muscles for tone and strength. Then assess for rigidity and spasticity. Rigidity is best detected in the wrist or elbow joint.

Appraising zip and grasp

Throughout the physical examination, ask the patient to show you how he buttons or zippers his clothing. This allows you to directly observe his ability to perform selected activities of daily living. Also observe him grasping items, such as a doorknob or water faucet.

Neurologic system
The neurologic examination includes assessment of LOC or awareness, affect, mood, cognition, orientation, speech, general knowledge, memory, reasoning, object recognition and higher cognitive functions, cranial nerves, motor and sensory systems, and reflexes.

Test time

To assess the older adult’s cognitive status, consider using a screening tool, such as the Mini-Mental Status Examination, the Short Portable Mental Status Questionnaire, or the Mental Status Questionnaire.

Monitoring mood

Start by observing your patient’s general appearance, including mood, affect, and grooming. An older adult who seems depressed may require further evaluation, as with the Geriatric Depression Scale. Note whether the patient is dressed appropriately, responds to questions appropriately, and is oriented to person, time, and place.
Next, assess the patient’s speech. Evaluate his vocabulary and general knowledge level by discussing current news items or family event s.

Memory, reason, and recognition
To evaluate memory, assess the patient’s immediate, recent, and remote recall.
• Check immediate recall by naming a certain number of objects or reciting a group of numbers and having him repeat them immediately.
• To elicit recent memory, ask him about events that occurred during the past 24 to 48 hours.
• To assess remote memory, ask him to recall significant events that occurred many years ago.

Reasoning and reckoning

Next, evaluate the patient’s ability to reason by asking questions that require judgment, insight, and abstraction to answer. To assess his object recognition, point to two objects and ask him to identify each one. Grade his response as normal or agnosia (inability to name objects).

Cranial nerves
Assess each cranial nerve sequentially, beginning with cranial nerve I and progressing to cranial nerve XII.

Motor and sensory systems
Evaluate the patient’s muscle and joint function. Assess for rapid, rhythmic, alternating movements, which reflect coordination. Observe whether he can repeat maneuvers, and watch for smoothness in executing them. Expect an older adult to respond more slowly than a younger person.

Probing perception

Next, check the patient’s pain perception, using the sharp and dull ends of a safety pin; temperature perception, using hot and cold substances; touch perception, using a light touch of the hand; and vibration perception, using a vibrating tuning fork. Also evaluate his two-point discrimination and position sense. His perceptions should be accurate and symmetrical.

Reflexes
Assess an older adult’s reflexes as you would in any other patient. Be sure to check for the plantar and Babinski’s reflexes, which may suggest upper motor neuron disease.

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