NCLEX-RN: Gerontological Nursing

Gerontological Nursing: Neurological System

Focus topic: Gerontological Nursing

Physiological Age Changes
A. Decreased speed of nerve conduction.
B. Delay in response and reaction time, especially with stress.
C. Diminution of sensory faculties.

  •  Decreased vision.
  •  Loss of hearing.
  • Diminished sense of smell and taste.
  •  Greater sensitivity to temperature changes with low tolerance to cold.

Assessment
A. Facial symmetry.
B. Poor reflex reactions; slowed reaction time.
C. Level of alertness—presence of organic brain changes.

  • Not all persons become confused.
  •  Most people have some memory impairment; learning takes longer.
  •  Change is gradual.
  •  Potential for accidents, falls.

D. Malnutrition—dehydration.
E. Eyes: movement, clarity, presence of cataracts.

  •  Level of visual impairment.
  •  Pupils: equality, dilation, constriction.
  •  Visual acuity—decreases with age.
    a. Do not test vision while client is facing window.
    b. Use handheld chart.
    c. Check condition of glasses.
  • Dry eyes—tearing is decreased.

F. Sensory deprivation—under stimulation or sensory overload.
G. Hypothermia.
H. Hearing acuity.

  • Hearing aid.
  •  Tinnitus.
  •  Cerumen in outer ear refer to specialist.

I. Presence of pain.
J. Sleep disturbances.
K. Depression.

Implementation
A. Maintain safety precautions.

  •  Evaluate reflex reactions to protect against accidents.
  •  Evaluate level of alertness.

B. Monitor dietary intake and fluid intake.
C. Provide adequate lighting to prevent falls.

  •  Natural lighting best.
  • Avoid glare.
  •  Nightlight at all times in bathrooms, halls.

D. Encourage sensory stimulation.

  •  Large-print books.
  •  Changes in environment.
  •  Colors client can see.

E. Maintain reality orientation.

  • Calendars.
  •  Clocks.
  •  One-to-one visits.

F. Keep client warm—prevent hypothermia.
G. Check sedative or hypnotic abuse for poor sleep patterns.
H. Check for antidepressant drugs.

Gerontological Nursing

Gerontological Nursing: Cardiovascular System

Focus topic: Gerontological Nursing

Physiological Age Changes
A. Structural changes.

  •  Mitral and aortic valves become sclerotic and calcified.
  •  Decreased baroreceptor sensitivity.
  •  Mild fibrosis and calcification of valves.

B. Cardiac output.

  •  Decreases 1% per year after age 20 due to decreased heart rate and decreased stroke volume.
  •  Force of contraction decreased.
  •  Ventricular wall thickens.
  •  Heart muscle decreased.

C. Vessels lose elasticity.

  •  Less effective peripheral oxygenation.
  • Position change from lying to sitting or sitting to standing can cause blood pressure to drop as much as 65 mm Hg.

D. Increased peripheral vessel resistance.

  •  Blood pressure increases: systolic may normally be 170 mm Hg, diastolic may normally be 95 mm Hg.
  •  Smooth muscle in arteries is less responsive.

E. Blood clotting increases.

 Assessment
A. Peripheral circulation, pulses, color, warmth.

  •  Widened pulse pressure.
  •  Jugular vein distention.

B. Circulatory status; orthostatic hypotension; hypertension.

  • Dizziness; fainting.
  •  Auscultate heart sounds.

C. Premature beats and dysrhythmias.
D. Edema—decreased venous return.
E. Activity intolerance.

  •  Weakness.
  •  Fatigue.

F. Dyspnea.
G. Transient ischemic attacks (TIAs).
H. Anemia.

Implementation
A. Monitor vital signs—pulse, blood pressure.

  •  Apical pulse for 1 minute so premature beats are not missed.
  •  Take blood pressure in both arms.

B. Monitor medications—digitalis, diuretics, etc.
C. Maintain dietary restrictions (low salt).
D. Change position slowly, especially from horizontal to vertical, to prevent hypotensive reaction.
E. Maintain circulatory homeostasis.

  •  Encourage activity to increase circulatory stimulation; leg exercises, leg elevation while sitting.
  •  Provide warmth by applying blankets and clothing.
  •  Use gentle friction during bath.
  •  Avoid tight/restrictive clothing.

Gerontological Nursing: Respiratory System

Focus topic: Gerontological Nursing

Physiological Age Changes
A. Respiratory muscles lose strength and become rigid.
B. Ciliary activity decreases.
C. Lungs lose elasticity (decreased breath sounds at base).

  • Residual capacity increases.
  • Larger on inspiration.
  •  Maximum breathing capacity decreases; depth of respirations decreases.

D. Alveoli increase in size, reduce in number.

  •  Fewer capillaries at alveoli.
  •  Dilated and less elastic alveoli.

E. Gas exchange is reduced.

  •  Arterial blood oxygen PaO2 decreases to 75 mm Hg at age 70.
  •  Arterial blood carbon dioxide PaCO2 unchanged.

F. Coughing ability is reduced—less sensitive mechanism.
G. Decline in immune response.
H. More dependent on the diaphragm for breathing.
I. System less responsive to hypoxia and hypercapnia (hypercarbia).
J. Ability to maintain acid–base balance decreased.

Assessment
A. Chest excursion.
B. Auscultate lungs/breath sounds.
C. Quality of cough, if present; sputum.
D. Rib cage deformity.
E. Dyspnea, hypoxia, and hypercapnia (hypercarbia).
F. Need for oxygen therapy.
G. Activity intolerance.
H. Anxiety.
I. Rate and rhythm.

Implementation
A. Manage airway clearance.

  •  Clean nares if nasal passages are clogged.
  •  Postural drainage, if necessary.

B. Monitor hydration status.
C. Promote respiratory activity with exercises.

  •  Teach deep-breathing exercises.
  •  Forced expiration.
  •  Coughing.

D. Monitor oxygen therapy.

  •  Caution: check for carbon dioxide narcosis.
  •  Symptoms: confusion, profuse perspiration, visual disturbance, muscle twitching, hypotension, cerebral dysfunction.

Gerontological Nursing: Gastrointestinal System

Focus topic: Gerontological Nursing

Physiological Age Changes
A. Tooth loss.

  •  Periodontal disease is major cause of loss after 30 years of age.
  •  Other causes include poor dental health, poor nutrition.
  •  Dentine decreased.
  • Gingival retraction.

B. Taste sensation and thirst decrease.

  •  When there is diminished sense of thirst, less water is consumed and dehydration may result.
  •  Atrophy of up to 80% of taste buds.
  •  Less sensitivity of those on tip of tongue first: sweet and salt.
  •  Less sensitivity of those on sides of tongue later: salt, sour, bitter.

C. Esophagus dilates, decreased motility, lower sphincter pressure decreases. Increased risk for aspiration.
D. Stomach.

  •  Hunger sensations decrease.
  •  Secretion of hydrochloric acid decreases.
  •  Emptying time decreases.

E. Peristalsis decreases and constipation is common.
F. Absorption function is impaired.

  •  Body absorbs fewer nutrients due to reduced intestinal blood flow and atrophy of cells on absorbing surfaces.
  •  Decrease in gastric and pancreatic enzymes affects absorption.

G. Hiatal hernia common (40% to 60% of elderly).
H. Diverticulitis (40% over age 70).
I. Liver.

  •  Fewer cells with decreased storage capacity.
  • Decreased blood flow.
  •  Enzymes decrease.
  •  Ability to regenerate decreases.
  • Hepatic protein synthesis is impaired.

J. Pancreas.

  •  Impaired pancreatic reserve.
  •  Ducts become distended.
  •  Lipase production decreased.

K. Decreased glucose tolerance.

Assessment
A. Tooth loss—poor dentition, inadequate chewing, weak swallowing reflex.
B. Condition of teeth, gums, buccal cavity.
C. Dietary intake—malnutrition.

  •  Anorexia; nausea and vomiting.
  •  Regurgitation.
  •  Anemia.

D. Indigestion, heartburn, pain, indications of possible hiatal hernia.
E. Bowel problems.

  •  Constipation, fecal impaction.
  •  Fecal incontinence.
  •  Diarrhea.

F. Drug toxicity.

Implementation
A. Monitor for adequate nutrition; stimulate appetite.

  •  Small, frequent feedings of high quality.
  •  Attractive meals, wine if allowed.
  •  Female, 1600 calories; male, 2200 calories.
  •  Preferred foods if possible; ethnic choices.

B. Lessen/prevent indigestion.

  • Fowler’s position for meals and keep upright 30 minutes after meals.
  •  Antacids contraindicated.
  •  Plan meals.
    a. Smaller meals without gas formers.
    b. Low fat.
    c. Avoid foods that cause distress.
  •  Adequate fluids; monitor for dehydration.

C. Prevent constipation.

  •  Ensure adequate bulk (fiber) and fluid in diet.
  •  Encourage activity.
  • Ensure regular and adequate time for bowel movement.
  •  Provide privacy and normal positioning.
  •  Administer laxative or suppository if above not effective. Note that laxatives are often abused—use with caution.

Gerontological Nursing: Genitourinary System

Focus topic: Gerontological Nursing

Physiological Age Changes
A. Kidneys.

  • Smaller due to nephron atrophy.
  •  Renal blood flow decreases 50%.
  •  Glomerular filtration rate decreases 50%.
  • Tubular function diminishes.
    a. Less able to concentrate urine; lower specific gravity.
    b. Proteinuria 1+ is common.
    c. Blood urea nitrogen (BUN) increases to 21 mg.
  •  Renal threshold for glucose increases.
  •  Potential for dehydration increases.
  •  Excretion of toxins and drugs decreases.
  •  Nocturia, frequency and urgency increase.

B. Bladder.

  •  Muscle weakens.
  •  Capacity decreases to 200 mL or less, causing frequency.
  • Emptying is more difficult, causing increased retention.
  •  Decreased sphincter control.
  • Less control, increased stress incontinence.

C. Age-related changes and associated clinical manifestations in male reproductive system.

  •  Prostate enlarges to some degree in 75% of men over age 65.
    a. Enlarges with age—hypertrophy.
    b. Difficulty initiating urine stream.
  •  Testicular volume decreases.
  •  Sperm count decreases.
  •  Seminal vesicles atrophy.
  •  Serum testosterone levels decrease with aging.
  •  Estrogen levels increase.
  •  Sexual response less intense.
  •  Longer to achieve erection.
  •  Erection maintained without ejaculation.
  •  Force of ejaculation decreased.

D. Age-related changes and associated clinical manifestations in female reproductive system.

  • Menopause occurs by mean age of 50.
  • Perineal muscle weakens.
  •  Vulva atrophies.
  • Vagina.
    a. Mucous membrane becomes dryer.
    b. Elasticity of tissue decreases, so surface is smooth.
    c. Secretions become reduced, more alkaline.
    d. Flora changes.
  • Estradiol, prolactin, progesterone diminish.
  •  Size of ovaries, uterus, cervix, fallopian tubes, labia decreases.
  •  Elasticity of the pelvic area decreases.
  •  Breast tissue decreases.
  • Intensity of sexual response decreases.
  •  Potential for vaginal infection increases.
  • Potential for vaginal and uterine prolapse increases.

E. Sexuality.

  • Older people continue to be sexual beings with sexual needs.
  •  No particular age at which a person’s sexual functioning ceases.
  •  Frequency of genital sexual behavior (intercourse) may tend to decline gradually in later years, but capacity for expression and enjoyment continue far into old age.
  •  Risk of sexually transmitted diseases (STDs) and acquired immune deficiency syndrome (AIDS) continues with age.

 Assessment
A. Dehydration, fluid intake and output (I&O).
B. Drug toxicity.
C. Urine: appearance, color, odor.
D. Bladder: frequency, urgency, hesitancy.

  •  Distention; incontinence.
  •  Males: difficulty initiating urine stream.

E. Nonspecific signs: fever, vomiting, dysuria, lower abdominal discomfort, hematuria for possible asymptomatic urinary tract infection or bladder cancer.
F. Sexuality—females.

  •  Vaginal irritation.
  • Painful coitus.

Implementation
A. Adequate fluid intake: 1500 mL minimum to 2500 mL daily.
B. Incontinence prevention.

  •  Offer opportunity to void every 2 hours.
  •  Provide easy access to bathroom.
  •  Keep nightlight in bathroom to prevent falls.
  •  Schedule diuretics for maximum effect during daylight hours.
  •  Limit fluids near and at bedtime.
  •  Teach female clients Kegel exercises to strengthen perineal muscles.
  •  Avoid caffeine.

C. Sexuality.

  •  Provide counseling if desired.
  •  Provide opportunity for desired sexual expression.
  •  Encourage touching and companionship, which are important for older people.

Gerontological Nursing: Musculoskeletal System

Focus topic: Gerontological Nursing

Physiological Age Changes
A. Contractures.

  •  Muscle mass decreases; regenerates slowly.
  • Tendons shrink and sclerose.

B. Range of motion of joints decreases.

  • Lack of adequate joint motion, ankylosis.
  •  Slight flexion of joints.

C. Mobility level.

  • Ambulate with or without assistance or devices.
  •  Limitations to movement.
  • Muscle strength lessens.
  • Gait becomes unsteady.

D. Kyphosis, such as postural changes with forward bend.
E. Intervertebral discs narrow, height diminishes by 1–4 inches (2.5–10 cm).
F. Trunk length decreases.
G. Redistribution of subcutaneous fat to abdomen/ hips.
H. Bone changes.

  •  Loss of trabecular and cortical bone.
  •  Decreased density.
  •  Become brittle.

I. Degeneration of the extrapyramidal tract.

 Assessment
A. Backward tilt of head (kyphosis).
B. Hips, knees, and wrists more flexed.
C. Decreased height (thinning discs).
D. Decreased movement; impaired mobility.
E. Muscle cramps and/or tremors.
F. Pain.
G. Decreased flexibility; stiff and enlarged joints.
H. Frequent falls.

Implementation
A. Ambulate within limitations.
B. Alter position every 2 hours; align correctly.
C. Prevent osteoporosis of long bones by providing exercises against resistance; calcium, vitamin D supplements.
D. Provide active and passive exercises.

  • Rest periods necessary.
  •  Paced throughout the day.

E. Provide range-of-motion exercises to all joints three times a day.
F. Educate family that allowing the client to be sedentary is not helpful.
G. Encourage walking, which is best single exercise for the elderly, and swimming.
H. Use assistive devices as needed.

Gerontological Nursing: Integumentary System

Focus topic: Gerontological Nursing

Physiological Age Changes
A. Skin is less effective as a barrier.

  •  Decreased protection from trauma.
  • Less ability to retain water.
  •  Decreased temperature regulation.
  • Decreased sensory receptors.

B. Skin composition changes.

  •  Dryness (xerosis) due to decreased endocrine secretion.
  •  Loss of elastin.
  • Increased vascular fragility.
  •  Thicker and more wrinkled on sun-exposed areas.
  •  Melanocyte cluster pigmentation.

C. Sweat glands.

  •  Decreased number and size.
  •  Decreased function of sebaceous glands.

D. Hair.

  • General hair loss.
  • Decreased melanin production.
  •  Facial hair increases in women, decreases in men, except in nose and ears—impacts sensory perception.

E. Nails are more brittle and thick.

Assessment
A. Skin.

  •  Temperature, degree of moisture, dryness.
  •  Intactness, open lesions, tears, pressure ulcers.
  •  Turgor, dehydration.
  •  Pigmentation alterations, potential cancer.
  •  Pruritus—dry skin most common cause.

B. Bruises, scars.
C. Condition of nails (hard and brittle).

  • Presence of fungus.
  • Overgrown or horny toenails; ingrown.

D. Condition of hair.
E. Infestations (scabies, lice).

Implementation
A. Bathing can minimize dryness.

  •  Have client take complete bath only twice a week.
  •  Use superfatted soap or lotions to aid in moisturizing.
  •  Use tepid, not hot, water.
  • Apply emollient (lanolin) to skin after bathing.

B. Clip facial hairs for female clients if desired.
C. Handle client gently to prevent skin tears.
D. Monitor for skin tears, bruising, and pressure ulcers.
E. Cut toenails unless contraindicated.

  •  Mycosis of nails.
  •  Certain medical/surgical conditions, such as diabetes, may require special order.

Gerontological Nursing: Endocrine System

Focus topic: Gerontological Nursing

Physiological Age Changes
A. Production of most hormones is reduced.
B. Parathyroid function and secretion are unchanged.
C. Pituitary decreases in weight and changes in cell type proportion. Significance is undetermined.

  • Growth hormone present, but in lower blood levels.
  • Reduced adrenocorticotropic hormone (ACTH), thyroid-stimulating hormone (TSH), follicle-stimulating hormone (FSH), and luteinizing hormone (LH) production.

D. Reduced thyroid activity.

  •  Decreased basal metabolic rate.
  •  Reduced 131I uptake.

E. Reduced aldosterone production.
F. Reduced gonadal secretion of progesterone, estrogen, testosterone.

FURTHER READING/STUDY:

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