NCLEX-RN: Gerontological Nursing

 Gerontological Nursing: Common Problems from Immobility

Focus topic:  Gerontological Nursing

 Gerontological Nursing: Pressure Ulcers

Focus topic:  Gerontological Nursing

Definition: Localized areas of necrosis of skin and subcutaneous tissue due to pressure or friction.

Characteristics
A. Cause—pressure or friction exerted on skin and subcutaneous tissue by bony prominence and the object on which body rests or against which it rubs.
B. Predisposing factors.

  • Malnutrition.
  • Anemia.
  •  Hypoproteinemia.
  •  Vitamin deficiency.
  •  Edema.
  • C. Common sites: bony prominences of body such as sacrum, greater trochanter, heels, elbows, etc.

Assessment
A. Stage of ulcer.
B. Identify if infection is associated with pressure ulcer.
C. Effectiveness of ulcer treatment.
D. Healing process of the ulcer.
E. Other bony prominences for potential formation of pressure ulcer.
F. Presence of conditions that inhibit wound healing.

Implementation
A. Prevention.

  •  Relieve or remove pressure.
  •  Avoid friction and shearing.
  •  Stimulate circulation.
  • Keep skin dry.

B. Positioning.

  •  Encourage client to remain active.
  •  Change position frequently—every 1–2 hours.

C. Maintain good skin hygiene; inspect frequently.
D. Provide for active and/or passive exercises.
E. Use alternating-air-pressure mattress, etc.
F. Avoid massaging bony prominences.
G. Provide for adequate nutritional and fluid intake.

 Gerontological Nursing: External Rotation of Hip

Focus topic:  Gerontological Nursing

Definition: Outward rotation of hip joint.

Characteristics
A. Cause—lying for long periods of time on back without support to hips.
B. Incorrect positioning in bed.

Implementation
A. Trochanter roll extending from crest of ileum to midthigh when positioned on back.
B. Frequent change of position.
C. Proper positioning.

 Gerontological Nursing: Foot drop

Focus topic:  Gerontological Nursing

Definition: Tendency for foot to plantar flex.

Characteristics
A. Causes.

  •  Prolonged bed rest.
  •  Lack of exercise.
  • Weight of bed clothing forcing toes into plantar flexion.

B. Complications.

  •  Individual walks on his or her toes without touching heel on ground.
  •  Unable to walk.

Implementation
A. Prevention.

  • Position feet against footboard.
  • Use foot cradle to keep weight of top linen off toes.
  •  Provide ROM exercises.

B. Check that soles of feet are against foot board to prevent permanent foot drop.

 Gerontological Nursing: Contractures

Focus topic:  Gerontological Nursing

Definition: Abnormal shortening of muscle, tendon, or ligament so joint cannot function properly.

Characteristics
A. Cause—improper alignment, lack of movement.
B. Result is decrease in mobility and joint movement.

Implementation
A. Proper alignment at all times.

  • Use pillows.
  •  Provide supportive splints.

B. Provide for ROM exercises.

 Gerontological Nursing: Bladder Dysfunction

Focus topic:  Gerontological Nursing

Definition: When an individual is unable to void and the reflex act of micturition (urination) cannot occur.

Characteristics
A. Causes.

  •  Disease process (urinary tract infection).
  •  Lack of innervation.
  • Lack of motivation.

B. Treatment involves bladder retraining, surgery, drugs.

Implementation
A. Bladder training—purpose.

  • Prevent urinary tract infection and preserve renal function.
  • Keep individual dry and odor free.
  •  Help individual maintain social acceptance.

B. Procedure.

  •  Set up specific time to empty bladder.
  •  Give measured amounts of fluids.
  • Position in normal voiding position.
  • Instruct client on how to perform Credé maneuver on the bladder.
  •  Keep record of amount and time of intake and output.
  •  Encourage client to wear own clothing, particularly underwear.
  • Provide protective underwear when needed.

 Gerontological Nursing: Bowel Dysfunction

Focus topic:  Gerontological Nursing

Definition: Normal elimination does not occur due to a structural problem or disease state.

Characteristics
A. Cause.

  • Disease process.
  • nadequate intake.
  •  Poor prior habits.

B. Treatment involves surgery, dietary modifications, or drugs.

Implementation
A. Identify purpose of bowel training.

  • Develop regular bowel habits.
  •  Prevent fecal incontinence, impaction, and/or irregularity.

B. Implement nursing procedure.

  •  Establish specific time.
  •  Provide for adequate roughage and fluid intake.
  • Use normal posture.
  •  Instruct to bear down and contract abdominal muscles.
  •  Provide privacy and time.
  • Provide exercise.
  •  Provide protective underwear when needed.

 Gerontological Nursing: Hypostatic Pneumonia

Focus topic:  Gerontological Nursing

Definition: Inflammatory process in which alveoli fill with exudates caused by a stagnation of blood flow in the dependent portion of the lungs.

Characteristics
A. Incidence.

  •  Very young, very old.
  • Debilitated.
  • Immobile (prolonged periods of bed rest).

B. Cause—stasis of secretions in lungs.

Implementation
A. Prevention.

  • Assess lung function.
  •  Encourage deep-breathing, coughing.
  • Turn every 2 hours.
  •  Out of bed (OOB)—chair when possible.
  •  Ensure adequate hydration.

B. Provide for postural drainage, if indicated.
C. Administer oxygen, as ordered.
D. Monitor antibiotic therapy.

 Gerontological Nursing: Problem Areas for Older Adult Clients

Focus topic:  Gerontological Nursing

 Gerontological Nursing: Sensory Impairment

Focus topic:  Gerontological Nursing

A. Elderly experience loss of function in the senses.

  • Ability to taste declines after age 40; taste buds are fewer in number and there is less saliva flow.
  •  Ability to smell declines.
  •  Hearing fades, especially in high-frequency ranges.
  • Regulation of body temperature is less efficient.

B. Major diseases or degeneration of organs occurs.

  •  Vision loss—see Chapter 8 pages 209–213 for nursing implications.
    a. Glaucoma—increased pressure causes damage to optic nerve, leading to blindness.
    b. Cataracts—clouding of the lens leading to blurred vision.
    c. Retinal detachment.
    d. Macular degeneration—loss of central vision due to degeneration of macula.
  •  Hearing loss—see Chapter 8 pages 213–214 for nursing implications.
    a. Otosclerosis requiring a stapedectomy.
    b. Hearing loss due to accumulation of earwax—requires periodic irrigation of auditory canal.

 Gerontological Nursing: Nutrition

Focus topic:  Gerontological Nursing

A. Physiological requirements do change (decrease) with age.

  •  Nutrition intake must meet two major demands.
    a. Normal structural repair.
    b. Energy production for functional needs.
  •  Met by protein and amino acids and adequate calorie intake.

B. Many older adults are deficient in nutrients, especially protein, B vitamins, vitamins A and C, iron, and calcium.

  • Change in diet is often responsible.
    a. Senses of taste and smell decrease, thus less conscious of hunger.
    b. Teeth in poor condition or dentures don’t work properly.
    c. Physical disabilities or lack of mobility; unable to buy groceries.
    d. Loss of interest in eating.
    e. Limited income affects buying nutritious food.
  •  System cannot assimilate nutrients as well as when younger.
    a. Reduced hydrochloric acid, reduced stomach activity.
    b. Decreased salivary flow.

C. Health status affects nutritional state.

  •  Chronic diseases: heart disease, cancer, diabetes, gastrointestinal problems, etc.
  •  Drugs: antacids, antidepressants, anticonvulsants, cathartics, diuretics, antimicrobials, etc.

D. Decreased physical activity and metabolic changes reduce caloric needs.
E. Financial resources, emotional, and physical state affect nutritional status.

Assessment
A. Hydration status, body weight, edema.
B. Anemia.
C. Appetite.
D. Ability to feed self—physical and mental.

  •  Dentition.
  •  Mastication.
  • Swallowing.
  • Desire to eat.

E. Fatigue, energy reserve.
F. Constipation.
G. Compliance to special diets.
H. Effects of drugs on nutrition.

  • Gastrointestinal irritation.
  •  Food–drug interactions.
  •  Some drug side effects are nausea and vomiting.

I. Skin and mucous membrane condition.

Implementation
A. Offer/give oral fluids in small amounts every hour.
B. Plan diet to be high in nutrients.

  •  Give foods with high fiber content.
  •  Balance of vitamins and minerals.
  •  Use lemon, vinegar, herbs on foods (rather than salt) to stimulate appetite.

C. Devise tools and plates that assist self-feeding.
D. Serve meals with others present to reduce isolation.

 Gerontological Nursing: Medications

Focus topic:  Gerontological Nursing

A. Thirty percent of all prescriptive drugs are used by older adults, and this does not include over-thecounter drugs.
B. Eighty percent of people age 65 and over have at least one chronic medical problem that requires medications (one-third have three or more chronic problems).
C. The typical older adult in the United States takes four to seven prescription drugs each day in addition to over-the-counter drugs (polypharmacy).
D. Often older adults have several medical problems for which they have different doctors, each prescribing different drugs.
E. Polypharmacy is responsible for 28% of hospital admissions.
F. Older adults (13% of the population) suffer 50% of all drug side effects (estimated 17 per 100,000 population).

  •  Increased risk for drug toxicity.
    a. Renal excretion altered—kidneys cannot process drugs as well.
    b. Liver enzymes altered.
    c. Diminished blood circulation to liver.
    d. May take multiple drugs that compete with each other.
    e. Central nervous system (CNS) more sensitive to drugs.
    (1) Drugs interfere with neurotransmitters (chemicals) that regulate brain function.
    (2) Side effects result in confusion.
    f. Lean body mass replaced by fat, so aging affects how much of the drug reaches bloodstream (e.g., Coumadin [warfarin sodium] and Lanoxin [digoxin] distributions in lean tissue may reach higher levels in older adults).
  •  Iatrogenic illness can be caused by drug therapy.
  • Most commonly abused drugs by older adults.
    a. Alcohol.
    b. Tranquilizers (most frequently abused).
    c. Sleeping pills.
    d. Medications to control pain.
    e. Laxatives.

G. Major problems with prescriptive drugs in older adults.

  •  Drug interactions—people who use multiple physicians and pharmacies run the risk of taking drugs that interact to cause adverse reactions.
    a. Some drugs use the same metabolic pathway and can result in hazardous blood levels.
    b. The combined effects of some drugs can be more potent than the physician intended.
  • Medication errors—the more medications a person takes, the greater the risk of medication error (people over age 75 take an average of 17 prescriptions annually).
  •  Opioids—produce greater analgesic effect in older adults.
    a. Opioid therapy should be initiated with 25% to 50% lower dose than that given to adults.
    b. Monitor for respiratory depression and reduced arterial O2 saturation.
    c. Monitor for other side effects: sedation, hypotension, urinary retention, constipation, etc.
  •  Noncompliance—not taking right dose at right time or discontinuing drug without consultation; common due to lack of understanding about reason to take drug and general knowledge base of drug action.
  • Unpredictable drug action—physiological changes associated with age and disease may alter effects of the drugs.
    a. Beta blockers—may increase respiratory or heart disease in clients with asthma, COPD, or heart failure.
    b. Nonsteroidal anti-inflammatory drugs (NSAIDs)—may increase gastrointestinal (GI) bleeding or worsen disease states.
    c. Psychotropic drugs—aggravate glaucoma or worsen heart block.
  •  Drug side effects not recognized—older adults not aware or do not understand potential dangerous side effects of drugs.
  • Inadequate monitoring—older adult is often alone or not monitored consistently so drug problems are not identified.
  •  Cost of drugs—multiple medications are costly for many older adults, so they stop taking drugs.

H. Preventing problems with drugs in older adults.

  •  Keep an up-to-date list of all drugs taken, including herbs, with dose and dosing schedule.
  • Take the list to every doctor seen, and to the pharmacy.
  •  Order all prescriptions from same pharmacy.Gerontological Nursing
  • Know the expected side effects of all drugs.
  •  Monitor for medications on the Beers Criteria— potentially inappropriate medication for use in older adults (American Geriatrics Society, 2012).

Administration of Medications
A. Oral route.

  •  Check for mouth dryness.
    a. Drug may stick and dissolve in mouth.
    b. Drug may irritate mucous membranes.
  • Place client in sitting position.
  • Crush tablets if they are very large.
  • Do not open capsules.
  •  Do not crush enteric-coated tablets.
  • Check with pharmacy for liquid preparations if client has difficulty swallowing tablets.

B. Topical medications will be absorbed more slowly.
C. Suppository.

  •  Position for comfort.
  •  May take longer to dissolve due to decreased body core temperature.
  • Do not insert suppository immediately after removing from refrigerator.

D. Parenteral.

  • Site may ooze medication or bleed due to decreased tissue elasticity.
  • Do not use immobile limb.
  • Danger of overhydration with intravenous (IV) administration.
  •  Decreased muscle mass may determine length of needle for injections.

E. Self-administration.

  •  Check compliance with amounts and times.
  •  Color code to facilitate proper administration.

Assessment
A. Changes in mental status.
B. Vital signs.

  •  Orthostatic blood pressure.
  • Apical pulse.

C. Urine production, retention.

D. Hydration and appetite.
E. Visual disturbances.
F. Swallowing ability.
G. Evaluate effects of drug.

  • Laboratory studies.
  • Signs and symptoms for toxic/interaction effects of drugs.

H. Bowel function.
I. Effects of nutrition and foods on drug response.

Implementation
A. No alcohol or alcohol-based elixirs when receiving benzodiazepines or antihistamines.
B. Method of administering drugs.

  •  Deep-breathing and relaxation to reduce use of analgesic drugs.
  •  Position client sitting with head slightly flexed to reduce chance of aspiration.

C. Administering tablets.

  •  Do not crush time-released or enteric-coated tablets.
  •  Crush large tablets if not contraindicated.
  •  Give with textured foods (nectar, applesauce) if not contraindicated.

D. Stroke victim—give drug on functional side of mouth.

 Gerontological Nursing: Pain in Older Adults

Focus topic:  Gerontological Nursing

Characteristics
A. More than 80% of all older adults suffer pain from chronic diseases.
B. Pain management is different with older adults.

  •  Underreported by older clients—may feel pain is a normal part of growing older.
  •  Physiology of the body affects absorption and metabolism of medication—pain drugs may have altered pharmacodynamics.

C. Important to recognize and assess pain in older adults or the results may affect the ability to function.

Assessment
A. Nonverbal cues to pain.

  •  Moaning or groaning.
  •  Restlessness or agitation.
  • Crying.

B. Verbal cues to pain.

  •  Reporting pain—try to establish a method of calibrating degree of pain (use pain scale that client understands).
  • Assessing if pain medication is working.

Implementation
A. Monitor pain cues closely, especially nonverbal ones.
B. Judge impact of pain on client—how much the pain contributes to poor functioning in activities of daily living.
C. Monitor pain relief methods.

  • Medications: see Medications section on preceding pages.
  • Provide pain relief through alternative methods (massage, acupuncture, relaxation, visualization, etc.).
  • Listen to client’s reports of pain relief and adjust care plan accordingly (if pain medication is not working, ask physician to change drug).

 Gerontological Nursing: Drug–Food–Herb Interactions in Older Adults

Focus topic:  Gerontological Nursing

A. Certain foods, vitamins/minerals, and “natural” remedies can interfere with therapeutic effects of drugs.

  •  Reduce absorption of drug.
  • Interfere with cellular action.

B. Medication regimen affected by nutrition may put client at risk.

  •  Important to assess client’s diet.
  •  Monitor potential vitamin–drug interactions.
  •  Certain drugs deplete essential nutrients; monitor client for low vitamin B complex, B12, etc.

C. Review client’s prescriptive and over-the-counter drugs.

  •  Review in relation to normal dietary intake.
  •  Consider vitamin/mineral intake and supplements in terms of decreasing effect of medications.
  •  Check lab values for problems.

D. Review herbs client is taking because interaction with medications may be dangerous.
E. Document findings so healthcare team is informed of diet/drug plan.
F. Food sources of vitamins and minerals.

  • Folic acid sources: liver, kidney, fresh vegetables.
  •  Niacin sources: yeast, meat, fish, milk, eggs, green vegetables, and cereal grains.
  • Pantothenic acid sources: meat, vegetables, cereal grains, legumes, eggs, milk, fish, and fruit.
  • Pyridoxine hydrochloride (vitamin B6) sources: cereal grains, legumes, vegetables, liver, meat, and eggs.
  •  Cyanocobalamin (vitamin B12) sources: animal foods, liver, kidney, fish, shellfish, meat, and dairy foods.
  •  Ascorbic acid (vitamin C) sources: fresh fruits and vegetables.
  •  Vitamin A sources: eggs, milk, cream, butter, organ meats, fish.
  • Vitamin D source: activated in body by sunlight.
  •  Vitamin E sources: vegetable oils, whole grains, animal fats, eggs, and green vegetables.
  •  Vitamin K sources: green leafy vegetables, spinach, broccoli, cabbage, and liver.

 Gerontological Nursing: Lab Values in Older Adults

Focus topic:  Gerontological Nursing

Urinalysis
A. Protein.

  •  Normal 0–5 mg/100 mL—rises slightly.
  •  May reflect changes in kidney or subclinical urinary tract infection.

B. Glucose.

  •  Normal 0–15 mg/100 mL—declines slightly.
  •  May reflect changes in kidney.

C. Specific gravity.

  •  1.010; changes to 1.024 by age 80 (older adults have a decreased thirst mechanism—drinking less water causes the specific gravity to increase).
  • Thirty to fifty percent decline in number of nephrons affects ability to concentrate urine.

Hematology
A. Hemoglobin.

  •  Men, 13–18 g/100 mL—drops 10–17 g/100 mL.
  • Women, 12–16 g/100 mL—no change.

B. Hematocrit.

  •  Men, 40–54%—no change.
  • Women, 37–48%—no change.

C. Leukocytes.

  •  4300–10,800/mm3—drops to 3100–9000/mm3.
  • As bone marrow diminishes, hematopoiesis declines.

D. Lymphocytes—1500–4500/mm3.

  •  T lymphocytes fall.
  • B lymphocytes fall.

E. Platelets, prothrombin time (PT), and partial thromboplastin time (PTT)—no change.

Blood Chemistry Tests That Change with Age
A. BUN.

  •  Men, 10–20 mg/100 mL—increases, may be as high as 69 mg/100 mL.
  • Women, 8–20 mg/100 mL—increases.
  • Renal function decreased due to decline in cardiac output, renal blood flow, and glomerular filtration rate.

B. Creatinine.

  •  0.6–1.2 mg/100 mL—increases as high as 1.9 mg/100 mL in men and women.
  • Endogenous creatinine is produced as lean body mass shrinks.
  • Drugs excreted by urinary system may cause toxicity if creatinine level is too high.

C. Creatinine clearance.

  •  104–132 mL/min (females); 110–150 mL/min (males).
  • Referenced interval: men’s formula for age: 140 – age × kg body weight divided by 72 × serum creatinine.
  • Reduced levels result in older adults more
    likely to develop toxicity to drugs excreted by kidneys.

D. Albumin.

  •  Decreases within the normal range—3.5 to 5.0 g/dL.
  • Increases with dehydration.

E. Glucose tolerance.

  •  One hour: 160–170 mg/100 mL. Two hours: 115–125 mg/100 mL. Three hours: 70–110 mg/100 mL.
  • With age, results rise more quickly in first 2 hours, then drop to baseline more slowly
  • Alcohol, monoamine oxidase (MAO) inhibitors, and beta blockers can all cause a rapid fall in glucose.

F. Fasting serum glucose.

  •  70–115 mg/dL increases with age.
  • Older adults are more prone to glucose intolerance and diabetes.

G.Thyroxine (T4) 4.5–13.5 μg/dL and triiodothyronine (T3) 90–220 μm/dL—both decrease by 25%.

Prescription for Long Life and Good Health
A. Regular exercise—older adults must continue to exercise regularly to maintain health (can increase function by 50% through exercise).
B. Nutritious diet—intake of adequate nutrients and calories to maintain body.

  •  Malnutrition contributes to high incidence of chronic disease.
  • Obesity contributes to increased health risks (heart disease, hypertension).
  • Diet adequate to maintain normal body weight, low fat, and include all four food groups for minimal nutrients, vitamins, and minerals.

C. No smoking—smokers die earlier than nonsmokers and have a higher incidence of heart disease, heart attack, cancer, and chronic lung disease.

D. Moderate alcohol intake; high alcohol intake is a health risk that leads to liver disease, nervous system damage, gastrointestinal problems.
E. Prevention of health problems—yearly physical examinations are important for older adults to diagnose an early disease process.

  •  Check warning signs of cancer, heart disease (hypertension).
  •  Pap smear and mammogram for women as precaution against cancer.
  •  Men should have prostate-specific antigen (PSA) test, along with exams for colon, prostate cancer.

F. Managing stress—stress is associated with increased incidence of heart disease, hypertension, cancer, and other diseases.
G. Maintain contact with friends for support; studies show that isolated older adults have more health problems and die earlier than people who have close attachments.
H. Smile more and give thanks daily.
I. Involvement in a community of faith indicates better health and outcomes in older adults.

FURTHER READING/STUDY:

Resources:

 

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