NCLEX-RN: Gerontological Nursing

Gerontological Nursing: Common Conditions in the Aged

Focus topic: Gerontological Nursing

Gerontological Nursing: Delirium

Focus topic: Gerontological Nursing

Definition: A cognitive disorder that may be reversible as opposed to dementia, which is irreversible.

Gerontological Nursing: Dementia

Focus topic: Gerontological Nursing

Definition: An organic condition resulting in an impairment of cognitive function manifested by long- and short-term memory loss with impaired judgment, abstract thinking, and behavior, resulting in self-care deficit.

Characteristics
A. Etiology is unknown.
B. Incidence is 5 million in the United States over age 65 (10% to 20% of the population).
C. Leading cause of institutionalization in older people. Of 1.3 million nursing home residents, one-half to two-thirds have some form of cognitive impairment.
D. A leading cause of death (120,000 annually).
E. Cost to society is $30 billion annually.
F. Ten to twenty-one percent of dementias are pseudodementias—reversible—may be related to depression.
G. Determine if false delirium is present.
H. Irreversible dementia: gradual onset with a progressive course.

  •  Fifty to 70% are Alzheimer type (most common).
  •  Fifteen to 25% are multi-infarct or vascular type.
  • Other types include Parkinson’s disease, alcohol abuse, Huntington’s chorea, intracranial mass.
Gerontological Nursing

Diagnosis
A. Diagnostic criteria must meet one criterion listed below.

  •  Sufficiently severe loss of intellectual abilities that interferes with social or occupational functioning.
  •  Memory impairment, usually of short-term memory.
  •  Impairment of abstract thinking or impaired judgment; disturbance of higher cortical function or personality change.
  •  Presence of a specific organic etiology or presumed presence.

B. Onset slow, insidious, unrelated to specific situation.
C. Gradual degeneration.
D. Mental status examination shows poor reality orientation, confusion, lack of understanding, etc.
E. History reveals symptoms.

  •  Onset slow; progressive decline.
  •  Personality changes, withdrawn.
  •  Confusion noted by others but not by client.
  • Early in the disease will attempt to find the right answer; later will not understand question.
  •  Unaware of memory loss.
    a. Begins with recent memory loss.
    b. Later, there are problems with coding and retrieving information.
  •  Oblivious to failures.

F. Possible predisposing factors: genetic, familial history of Down syndrome, enzyme deficiency, immune system deficiency, aluminum toxicity, acetylcholine (a neurotransmitter) deficiency.

Assessment
A. Adequate physical health; usually not affected.
B. Intellectual impairment; complete a mini-mental assessment tool.

  • Alertness.
  • Orientation.
  •  Appropriate responses to questions.
  • Aphasia, may produce words but not sentences.
  •  Does not recognize staff or family.

C. Behavior.

  • Performance of grooming and hygiene tasks gradually diminishes.
  • Cooperative.
  • Distracted.
  •  Agitated.
  • Paranoid, delusions.
  • Restless.
  •  Wandering behavior (frequently at sundown).

D. Motor responses.

  •  Stability of gait (motor ability declines).
  • Functional position of limbs/joints.

E. Condition of skin.
F. Bowel and bladder function—incontinent.

Implementation
A. Provide safe environment to prevent falls, unsafe wandering.
B. Monitor medications.

  • Give lowest dose of antipsychotic (one-fourth the dose of a middle-aged adult).
  •  Evaluate effect of antipsychotic, antidepressant, antianxiety medication.

C. Use clear, verbal communication techniques.

  •  Short words, simple sentences, verbs, and nouns.
  •  Call client by name and identify yourself.
  • Speak slowly, clearly; wait for response.
  •  Ask only one question, give one direction at a time.
  • Repeat, do not rephrase.

D. Use nonverbal communication.

  • Approach in a calm, friendly manner.
  • Use gestures, move slowly.
  •  Stand directly in front of client; maintain eye contact.
  • Move or walk with client; do not try to stop.
  •  Listen actively; show interest.
  •  Chart all phrases and nonverbal techniques used and use those that “work.”

E. Monitor activities of daily living.

  •  Orient to environment and activity on a “here and now” basis.
  •  Provide consistent routine with activities.
  • Remind how to perform self-care activities as dressing, eating, toileting.
  •  Avoid activities that tax the memory.
  • Give tasks that distract and occupy, such as listening to music, coloring, watching TV.

F. Assess suicide risk in early stages.
G. Maintain the client’s physical activity within limits of safety.

  •  Walk outside if grounds are “wander protected” (fenced, alarmed) or if accompanied.
  •  Dance.
  •  Exercises with simple commands.
  • Active games.
  •  Balance activities.
  • Activities of daily living.

H. Provide mental stimulation.

  •  Simple hobbies.
  •  One-to-one contact.
  •  Reality orientation.
  • Play word or number games.

I. Use consistent staff to provide care; change is frightening.
J. Encourage self-care; give cues. Pantomime brushing teeth instead of brushing client’s teeth.
K. Put families in touch with support groups such as Alzheimer’s Disease and Related Disorders Association, Inc. (ADRDA) chapters.

Gerontological Nursing: Depression

Focus topic: Gerontological Nursing

Definition: A mood disorder dominated by sadness, gloomy attitude, hopelessness, and a lack of pleasure in life.

Characteristics
A. Seven to eleven percent of community-based older adults are depressed; 1% to 2% suffer from major depression.
B. Most commonly treated disorder in older adults.
C. Fifteen percent of all older adults suffer from this problem (double the normal population).
D. Often mistaken for “hardening of the arteries” or other type of dementia.
E. Depression leads to other major problems, increasing the susceptibility to disease.

  •  Undernourishment.
  •  Dehydration.
  •  Inactivity.
  •  Self-neglect.
  •  Isolation.

Assessment
A. History of depression.

  • Loss of interest in life.
  •  Sense of hopelessness and sadness.
  •  Difficulty sleeping.
  •  Weight loss due to loss of interest in food.
  •  Fatigue.
  •  Reduced sexual desire.

B. History of multiple losses.

  •  Death of a spouse, friends.
  •  Loss of job-related challenges and focus.
  •  Loss of normal physical functioning.
  •  Loss of social interaction and contacts; isolation.
  •  Loss of self-esteem.

C. Complaints of memory loss.
D. Complaints of physical pain.
E. Drug side effects.
F. Potential suicide risk—high incidence in the older population.

  •  With depression comes high risk for suicide.
  • The suicide rate for 75- to 85-year-old white males is 53 per 100,000.
  •  Most significant risk factor is recent loss of major relationship.
  •  Assess for specific cues related to suicide.
    a. Hopeless talk about the future.
    b. Hints: “Things will change soon.”
    c. Relates plan for ending life.
    d. Gives away belongings.

Implementation
A. Implement safety precautions for suicide risk (see Suicide section in Chapter 14, Psychiatric Nursing).
B. Establish daily activities to reinforce positive experiences.

  •  Give some area of control or power to person.
  • Provide variation in daily schedule but not too many changes, as change is anxiety producing for the elderly.

Gerontological Nursing: Hip (Femoral Neck) Fracture

Focus topic: Gerontological Nursing

Definition: Fracture at femoral neck can result in a vascular necrosis: death of the bone due to insufficient blood supply. Occurs most frequently in elderly women.

Characteristics
A. Usually results from a fall.
B. Directly related to loss of bone strength due to osteoporosis.
C. People over age 65 account for 87% of hip fracture cases.

  • More than 250,000 occur each year.
  •  Most are women.

D. Fourteen to 36% of older clients with complications die.
E. More than 25% of survivors lose their ability to walk independently.
F. Sixty percent do not regain their preinjury level of ambulation.
G. Personal and social consequences for older adults.

  • Restriction of daily activities can result in depression, complications, etc.
  • Hospitalization adds financial burden, dependence.

Assessment
A. Assess for pain, tenderness, or muscle spasm over fracture site or in groin.
B. Assess for lateral rotation and shortening of leg with minimal deformity.
C. Degree of disability.
D. Elimination problems.
E. Nutritional status.
F. Emotional reaction to immobility.
G. Degree of support from family.

Implementation
A. Operative procedure.

  •  Femoral head replacement—surgical fixation with nails, pins, or screws.
  •  Occasional total hip replacement.

B. Preoperative care.

  •  Provide care such as that given to clients in skin traction.
    a. Buck’s extension may be applied to relieve muscle spasm at the fracture site.
    b. Movement of fracture fragments will increase muscle spasms and pain.
  • Observe for elimination regularity.
  • Teach coughing and deep-breathing. Encourage isometric exercises and use of overhead trapeze.
  •  Maintain proper positioning—splinting injured leg with pillows on unaffected side.
  • Assist client with eating; nourishing diet is essential for healing process.

C. Postoperative care.

  •  Turn client from unaffected side to back as routine, turn every 2 hours; a physician’s order is required to turn from side to side.
  •  Turn client with hip prosthesis by always placing pillows between legs to avoid adduction.
  • Elevate head; may be limited to 30 to 40 degrees to avoid acute hip flexion.
  •  Introduce quadriceps and gluteal setting muscle exercises; encourage use of overhead trapeze for assistance in moving.
  •  Take measures to protect client when moving from bed to chair (client not to bear weight on affected leg).
  •  Provide routine postoperative measures to ensure client’s comfort.
  • Take measures as necessary to prevent complications.
    a. A vascular necrosis of femoral head.
    b. Nonunion.
    c. Pin complications.
    d. Dislocation of prosthesis.
    e. Infection.

Gerontological Nursing: Urinary Incontinence

Focus topic: Gerontological Nursing

Definition: Involuntary release of urine of such severity as to have social and/or hygienic consequences.

Characteristics
A. Ten million adults are incontinent—over half the residents of nursing homes and one-third of elderly living at home are affected.
B. Prevalence rises with age.
C. This condition is not a normal consequence of aging; it is a symptom signaling the presence of other problems.
D. Types.

  • Stress incontinence: result of sudden increase in intra-abdominal pressure that pushes urine out of the bladder.
  •  Urge incontinence: leakage of urine before one reaches the toilet usually caused by uncontrolled contraction of the bladder.
  • Overflow incontinence: constant dribble of urine results when bladder is not completely emptied during voiding.
  • Functional incontinence: non-organic; impaired mobility, depression, and dementia can prevent client from reaching bathroom.

Assessment
A. Assess pattern of problem—see types of incontinence as noted above.

  • Decreased bladder tone/volume.
  •  Muscle tone—urgency and frequency.

B. Presence of other problems, disease states, or change in physical health.

  •  Congestive heart failure (CHF).
  •  Urinary tract infection.
  •  Pneumonia.
  • Stool impaction.

C. Effects of medication(s).
D. Smoking.
E. Environmental problems.

  •  Access to toilet.
  •  Restraints.
  •  Privacy.
  •  Response of staff/family.

F. Skin condition.
G. Emotional coping in relation to the problem.

Implementation
A. Monitor medical treatment.

  •  Pelvic floor muscle exercises (Kegel exercises) and behavioral training (biofeedback).
  •  Drug therapy.
    a. Anticholinergic drugs: Pro-Banthine (propantheline).
    b. Antispasmodic drugs: Ditropan (oxybutynin)— inhibit bladder contractions.
  •  Perform surgery to strengthen pelvic muscles, repair a damaged urethra, and/or remove an obstruction.

B. Provide appropriate skin care.
C. Establish toileting schedule.

  •  Easy access.
  •  Appropriate clothing—client’s own, if possible.

D. Assist client to learn Kegel exercises.

  •  Will help to control stress and urge 2. Steps are to contract pubococcygeus muscle, hold contraction for 10 seconds, and relax for 10 seconds. Work up to 25 repetitions 3 times  per day.

E. Provide protection plan for accidents.

  •  Accidents are embarrassing and often limit excursions and social activities.
  •  Prevent problems and avoid disrupting client’s life.

F. Devise ways to build client’s self-esteem.

  •  Positive reinforcement.
  •  Plan activities that client can enjoy.incontinence.

Gerontological Nursing: Impaired Mobility/Disability

Focus topic: Gerontological Nursing

Definition: Older adults can suffer impaired mobility and disability due to decreased physical function and/or accidents.

Characteristics
A. Nearly 23% of older people living in the community have some degree of disability.

  •  Those 85 and older constitute a disproportionate share of those who are dependent in physical functioning.
  •  Those 85 and older constitute 27% of those who have impaired mobility.

B. Impaired mobility can lead to many subsequent problems: depression, negative self-image, dependent behavior, loss of independence, etc.
C. Effects of disability.

  •  Impact on the individual’s body image.
    a. Physical appearance.
    b. Bodily sensations.
  •  Behavior during reaction period.
    a. Appears confused and disorganized.
    b. Denies disability exists.
    c. Overreacts to situations and physical condition.
    d. Assumes false-positive attitude.
    e. Becomes self-centered.
    f. Becomes depressed.
    g. Mourns loss of function or body part.
  •  Adaptation and adjustment.
    a. Revises body image by modifying former picture of self.
    b. Reorganizes values.
    c. Accepts degree of dependency.
    d. Accepts limitations imposed by disability.
    e. Begins to develop realistic goals.

Assessment
A. Specific source of disability or impaired mobility.
B. Presence of accompanying disease state: arthritis, stroke, dementia, diabetes, CHF, chronic obstructive pulmonary disease (COPD).
C. Strength and function of limbs and joints.
D. Stability of gait.
E. Presence of pain.
F. Condition of skin.
G. Drug effects—sedation, incontinence, orthostatic hypotension.
H. Motivation for rehabilitation.
I. Nutritional status.
J. History of falls.

Implementation
A. Develop nursing care plan to meet client’s needs.
B. Focus on disability or impaired mobility.
C. Establish supportive relationship.
D. Teach activities of daily living.

  •  Activities that must be accomplished each day for the individual to care for own needs and be as independent as possible.
  •  Ascertain best assistive aid for client.
  •  Demonstrate and encourage individual to practice.
  •  Increase activities as individual progresses and is able to assume activity.
  • Give positive reinforcement for all effort expended.

E. Prevent deformities and complications.

  •  Turn and position in good alignment.
    a. Prevent contractures.
    b. Stimulate circulation.
    c. Prevent thrombophlebitis.
    d. Prevent pressure ulcers.
  •  Prevent edema of extremities.
  •  Promote lung expansion.

 Types of Exercise for Rehabilitation
A. Passive.

  •  Carried out by the therapist or nurse without assistance from client.
  •  Purpose—retain as much joint range of motion as possible, and maintain circulation.

B. Active assistive.

  •  Carried out by the client with assistance of therapist or nurse.
  • Purpose—encourage normal muscle function.

C. Active.

  •  Accomplished by the individual without assistance.
  • Purpose—increase muscle strength.

D. Resistive.

  • Active exercise carried out by the individual working against resistance produced by manual or mechanical means.
  • Purpose—provide resistance to increase muscle power.

E. Isometric or muscle setting.

  • Performed by the individual without assistance.
  •  Purpose—maintain strength in a muscle when a joint is immobilized.

F. Range of motion (ROM).

  •  Movement of a joint through its full range in all appropriate planes.
  •  Purpose—maintain joint mobility and increase maximal motion of a joint.
  •  Nursing care.
    a. Assess general condition of client.
    b. Establish extent of ROM before present
    condition.
    c. Discontinue ROM at point of pain.
  •  Deterrents to ROM exercises: fear and pain.

Use of Aids/Devices
A. Cane.

  •  Purpose.
    a. Provide greater stability and speed when walking.
    b. Relieve pressure on weight-bearing joints.
    c. Provide force to push or pull body forward.
  •  Safety factors.
    a. Handle at level of greater trochanter.
    b. Elbow flexed at 25- to 30-degree angle.
    c. Lightweight material.
    d. Rubber suction tip.
  •  Techniques for walking with cane.
    a. Hold cane close to the body.
    b. Hold in hand on unaffected side.
    c. Move cane at same time as affected leg.

B. Crutches.

  •  Purpose—provide support during ambulating when lower extremities unable to support body weight.
  • Safety factors.
    a. Measure 1½ to 2 inches (3.8 cm to 5.08 cm) from axillary fold to floor (4 inches [10.16 cm] in front and 6 inches [15.24 cm] to side of toes).
    b. Hand piece adjusted to allow 30-degree elbow flexion.
    c. Rubber suction tips on crutches.
    d. Well-fitting shoes with nonslip soles.

C. Prosthesis—artificial replacement for a missing body part.
D. Brace—support that protects or supports weakened muscles.

Gerontological Nursing: Infections in Older Adults

Focus topic: Gerontological Nursing

A. Older clients are more susceptible to infection— diminished resistance.
B. Important to recognize high-risk clients.
C. Diseases that contribute to high risk.

  •  Diabetes mellitus.
  •  CHF.
  •  Malignancy—double risk due to chemotherapy depressing the immune system.
  •  Renal failure.

D. Conditions that make clients prone to infection.

  •  Dehydration.
    a. Fluid depletion—skin more penetrable by pathogens.
    b. Thick mucosal secretions—coughing more difficult.
  •  Increased urinary retention.
    a. Monitor fluid intake.
    b. 1500 to 2500 mL daily.
  •  Bed confinement.
    a. Increases risk of renal infection by causing urine back flow through ureters up into kidneys.
    b. Voiding while bedridden increases pressure on bladder, adds to risk of urinary tract infection.
    c. To minimize risk, assist client to sit or stand when voiding, if possible.
  •  Poor skin turgor; less effective as barrier to trauma.
    a. Less resistance to friction increases risk of pressure ulcers.
    b. Maintaining nutrition and fluid intake lessens risk.
  • Bowel problems lower resistance.
    a. Constipation may lead to intestinal obstruction and perforation.
    b. Prevention—fiber-rich fruits and vegetables, whole-grain breads and cereals.

E. When infection develops.

  •  Older person may not show a fever (baseline may be low so slight increase is not noted).
    a. Take baseline temperature.
    b. Lower temperature only when it goes above 102 to 104°F (38.8 to 40°C). (Fever inhibits bacterial and viral growth.)
    c. Evaluation of antibiotic therapy (fever decreases) is more accurate without antipyretic.
  • Older clients are more susceptible to adverse effects of antibiotics.
    a. Hearing loss—especially with isoniazid and aminoglycosides.
    b. Vertigo with aminoglycosides.
    c. Monitor BUN and creatinine levels to check for nephrotoxicity: Garamycin (gentamycin), Tobrex (tobramycin), and Vancocin (vancomycin).

d. Diarrhea: Omnipen (ampicillin), Panmycin (tetracycline), Chloromycetin (chloramphenicol) leads to electrolyte imbalance.
e. Increased risk of yeast infection.

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