- FURTHER READING/STUDY:
- EKG: Atrial/AV Nodal and Junctional Dysrhythmias
- EKG: Sinus Node Related Dysrhythmias
- NCLEX: Ear, nose, and throat disorders
- NCLEX: Clinical Toxicology
- NCLEX: Immunosuppressants
- NCLEX: Anticancer Drugs
- NCLEX: Eye disorders
- EKG: Axis, Hypertrophy, and Bundle Branch Blocks
Physiological Integrity: Nursing Care of the Geriatric Client: Introduction
Focus topic: Physiological Integrity: Nursing Care of the Geriatric Client
This chapter is unique in that the primary objective is to present practical, concise information of clinical relevance for the beginning practitioner that is not covered elsewhere. The focus is on 12 significant problems and concerns associated with the older adult: falls, use of restraints, thermoregulation, sleep disturbance, skin breakdown, polypharmacy, specific types of hearing changes, age-related macular degeneration, incontinence, sexual neglect, caregiver burden, warning signs of poor nutrition.
I. HEALTH ASSESSMENT OF THE GERIATRIC CLIENT
Focus topic: Physiological Integrity: Nursing Care of the Geriatric Client
- Decrease in elasticity → wrinkles and lines, dryness.
- Loss of fullness → sagging.
- Generalized loss of adipose and muscle tissue → wasting appearance.
- Decrease of adipose tissue on extremities, redistributed to hips and abdomen in middle age.
- Bony prominences become visible.
- Excessive pigmentation → age spots.
- Dry skin and deterioration of nerve fibers and sensory endings → pruritus.
- Decreased blood flow → pallor and blotchiness.
- Overgrowth of epidermal tissue → lesions (some benign, some premalignant, some malignant).
- Dry, brittle, peeling, ridges.
- Increased susceptibility to fungal infections.
- Decreased growth rate.
- Toenails thick, difficult to cut, ingrown.
- Loss of pigment → graying, white.
- Decreased density of hair follicles → thinning of hair.
- Decreased blood flow to skin and decreased estrogen production → baldness.
a. Hair distribution: thin on scalp, axilla, pubic area, upper and lower extremities.
b. Decreased facial hair in men.
- Decreased estrogen production → increased facial (chin, upper lip) hair in women.
- Loss of soluble protein with loss of lens
- transparency → development of cataracts.
- Decrease in pupil size limits amount of light entering the eye → elderly need more light to see.
- Decreased pupil reactivity →decrease in rate of light changes to which a person can readily adapt.
- Decreased accommodation to darkness and dim light → diminished night vision.
- Loss of orbital fat → sunken appearance.
- Blink reflex—slowed.
- Visual acuity—diminished.
- Peripheral vision—diminished.
- Visual fields—diminished (e.g., macular degeneration).
- Lens accommodation—decreased; requires corrective lenses.
- Presbyopia—lens may lose ability to become convex enough to accommodate to nearby objects; starts at age 40 (farsightedness).
- Color of iris—fades.
- Conjunctiva—thins, looks yellow.
- Increased intraocular pressure → glaucoma.
- Previous corrective surgery.
- Changes in cochlea → decrease in average pitch of sound.
- Hearing loss—greater in left ear than right; greater in higher frequencies than in lower.
- Tympanic membrane—atrophied, thickened → hearing loss.
- Presbycusis—progressive loss of hearing in old age.
- Use of hearing devices.
- Predisposed to wax buildup (cerumen).
F. Mouth/dental health:
- Dental caries.
- Poor-fitting dentures; no dentures.
- Cancer of the mouth—increased risk.
- Decrease in taste buds → inability to taste sweet/salty foods.
- Olfactory bulb atrophies → decreased ability to smell due to blockage or disease of olfactory receptors in the upper sinus → decreased awareness of body odor, smoke, fumes, spoiled food.
- Coating of tongue.
- Lack of elasticity of vessels → increased resistance to blood flow; decreased diameter of arteries → increased blood pressure.
- Atherosclerotic and calcium plaques → thrombosis.
- Valves become sclerotic, less pliable → reduced filling and emptying.
- Diastolic murmurs heard at base of heart.
- Loss of elasticity, decreased contractility → decreased cardiac output.
- Changes in the coronary arteries → pooling of blood in systemic veins and shortness of breath → reduced pumping action of the heart.
- Disturbance of the autonomic nervous system → dysrhythmias.
- Extremities—arteriosclerotic changes → weaker pedal pulses, colder extremities, mottled color; pain with ambulation.
- Efficiency reduced with age.
- Greater residual air in lungs after expiration.
- Decreased vital capacity.
- Weaker expiratory muscles → decreased capacity to cough → infections of lower respiratory tract.
- Decreased ciliary activity → stasis of secretions → susceptibility to infections.
- Oxygen debt in the muscles → dyspnea on exertion (DOE), sleep apnea due to ↓ O2 to the brain.
- Reduced chest wall compliance → decreased expiratory excursion, affecting inspiratory and expiratory volumes.
- Cancer risk—increased with age.
- Lack of intrinsic factor → pernicious anemia.
- Gastric motility—decreased → poorer, slower digestion.
- Esophageal peristalsis—decreased.
- Hiatal hernia—increased incidence.
- Digestive enzymes—gradual decrease of ptyalin (which converts starch), pepsin and trypsin (which digest protein), lipase (fat-splitting enzyme).
- Improper diet → constipation.
- Decreased thirst sensation → risk for dehydration.
- Decreased saliva → dysphagia.
- Basal metabolism rate lowered → decreased temperature.
- Cold intolerance.
- Women: decreased ovarian function → increased gonadotropins.
- Decreased renal sensitivity to antidiuretic hormone (ADH) → unable to concentrate urine as effectively as younger persons.
- Decreased clearance of blood glucose after meals → elevated postprandial blood glucose.
- Risk of diabetes mellitus increases with age.
- Renal function—impaired due to poor perfusion.
- Filtration—impaired due to reduction in number of functioning nephrons → decrease in urine concentration.
- Urgency and frequency: men—often due to prostatic hyperplasia; women—due to perineal muscle weakness.
- Nocturia—both men and women.
- Urinary tract infection (e.g., cystitis)—increased incidence.
- Incontinence—especially with dementia; stress/exercise induced.
- Retention—due to incomplete bladder emptying.
- Muscle mass—decreased. Loss of lower limb strength.
- Bony prominences—increased.
- Demineralization of bone.
- Narrowing of intervertebral space → shortening of trunk → loss of height.
- Posture—normal; some kyphosis.
- Range of motion—limited.
- Osteoarthritis—related to extensive physical activities and joint use.
- Gait—altered; use of cane or walker.
- Osteoporosis related to menopause, immobilization, elevated levels of cortisone → increase in fractures.
- Calcium, phosphorus, and vitamin D decreased.
- Voluntary, automatic reflexes—slowed.
- Sleep pattern—changes.
- Mental acuity—changes.
- Sensory interpretation and movement— changes.
- Pain perception—diminished.
- Dexterity and agility—lessened.
- Reaction time—slowed.
- Memory—past more vivid than recent memory due to loss of neurons from CNS.
- Alzheimer’s disease.
- Estrogen production—decreased with menopause.
- Vaginal secretions—reduced lubricants.
- Sexuality—drive continues; sexual activity declines.
- Testosterone production—decreased.
- Testes—decrease in size; decreased sperm count.
- Libido and sexual satisfaction—no changes.
P. Mental status: the “3 Ds”:
- Delirium: confusion/agitation with time and place disorientation, illusions and/or hallucinations.
- Dementia: cognitive deficits (memory, reasoning, judgment).
- Depression: decreased interest/pleasure in activities.
Q. Immune system:
- Immune response: decreased → decreased T-cell activity and decrease in cell-mediated immunity.
- Increased risk of nosocomial infections (e.g., Pseudomonas, staphylococci, enterococci, and fungi), pneumonia, cancer, reactivation of varicella-zoster virus and tuberculosis (TB).
- Atypical inflammatory response; no elevated temperatures or white blood cell counts.
II. GENERAL NURSING DIAGNOSES IN THE GERIATRIC CLIENT
Focus topic: Physiological Integrity: Nursing Care of the Geriatric Client
- Risk for loneliness related to isolation and loss of many friends, family members, and pets due to separation and death.
- Self-care deficit related to inability to complete activities of daily living.
- Impaired verbal communication related to hearing loss.
- Fluid volume deficit related to low fluid intake.
- Impaired skin integrity related to prolonged back-lying position and inability to turn self.
- Body image disturbance related to physical changes associated with the aging process.
- Sleep pattern disturbance related to concern about outcomes of pending diagnostic tests.
III. PROBLEMS ASSOCIATED WITH THE GERIATRIC CLIENT*
Focus topic: Physiological Integrity: Nursing Care of the Geriatric Client
- Assessment. Risk factors:
a. Gait changes—prone to trip and stumble; do not pick feet up as high.
b. Postural instability—tendency to lose balance; older adults take steps to correct balance and increase possibility of falling.
c. Impaired muscular control—inability to recover from trip or unexpected step; weaker muscle cushioning and slowed righting reflexes.
d. Deterioration of vision and hearing— impaired ability to avoid obstacles.
e. Loss of short-term memory—prone to trip over forgotten objects.
(1) Home: unstable furniture and appliances; stairs with poor rails; throw rugs and frayed carpets; poor lighting; low beds and toilets; pets; objects on floor; medications.
(2) Institutions: recent admission or transfer; furniture; slick, hard floors; unsupervised activities; mealtimes; absence of handrails; inadequate lighting, long hallways.
- Reduce risk of falling in the older adult with fall prevention measures.
a. Treat underlying condition (e.g., osteoporosis, muscle weakness, imbalance, pain).
b. Reduce risk factors (e.g., visual problems, orthostasis).
c. Reduce environmental hazards (e.g., provide adequate lighting and night lamps, avoid cluttered areas, no throw rugs, provide bath and shower support bars).
d. Increase leg range-of-motion (ROM) exercises.
e. Develop an individualized exercise plan.
f. Support adequate nutrition (e.g., calcium intake).
B. Use of restraints:
Definition—any device, material, or equipment attached to the client that cannot be easily removed by the client; restricts free movement; includes leg restraints, arm restraints, hand mitts, soft ties or vests, wheelchair safety bars, “geri-chairs.”
- Assessment of problems resulting from use of restraints:
a. Increased agitation, confusion.
c. Pressure sores.
d. Bone density loss (demineralization).
e. Immobility hazard.
f. Death from strangulation.
- Nursing goal/implementation: provide restraint-free care with alternatives to restraints.
a. Physical: recliners; medications for pain relief; seating adaptations (physical therapy/ occupational therapy); chairs with deep seats.
b. Psychosocial: encourage expression of feelings, giving time for client response; encourage positive self-concept; offer hope; active listening; increased or decreased sensory stimulation; increased visiting; reality orientation; clocks; animals.
c. Activity: structured daily routines; wandering/ pacing permitted; physical exercise; nighttime activities.
d. Environmental: door buzzers; limb bracelet alarms; signs, call bells.
e. Structural: exit alarms; increased lighting; enclosed courtyards.
f. Supervision: family, nursing; volunteer; security.
C. Thermoregulation—normal oral temperature for greater than 75 years of age: oral, 96.9° to 98.3°F; rectal, 98° to 99°F. Decreased or absence of increased temperature in infection or dehydration.
- Assessment of causes:
a. Factors affecting the hypothalamus: decreased— muscle activity, metabolic rate, food and fluid intake, subcutaneous fat; changes in peripheral blood flow; diseases; medications.
b. External factors: environmental temperature; humidity; airflow; type and amount of clothing.
- Nursing goal/implementation: prevent hypothermia and hyperthermia.
a. Ensure and monitor adequate fluid and food intake.
b. Maintain constancy in environmental temperature: avoid drafts, overheating, prolonged exposure to cold.
c. Monitor ventilation: provide airflow (air conditioners, fans; safe sources of heat).
d. Use layered clothing (remove when warm; add when cold).
D. Sleep disturbances.
- Nursing goal/implementation: promote restful sleep and prevent sleep deprivation with sleep care strategies.
a. Maintain normal sleep pattern: arrange medications and therapies to minimize sleep interruptions.
b. Encourage daytime activity; discourage daytime naps.
c. Support bedtime routines/rituals: bedtime reading, listening to music, quiet television.
d. Promote comfort: mattress, pillows, wrinkle-free linens, loose bed covering.
e. Promote relaxation: warm milk or soup if not contraindicated, back rub.
f. Avoid/minimize stimulation before bedtime: no caffeine after dinner, reduce fluid intake before sleep, refrain from smoking.
g. Avoid/minimize drugs that negatively influence sleep, such as ranitidine, diltiazem, atenolol, nifedipine.
h. Create a restful environment: turn off lights, reduce or eliminate noise, minimize disruptions for therapy or monitoring.
E. Skin breakdown.
a. Age-related changes: slower rate of epidermal proliferation; thinner dermis; decreased— dermal blood supply, melanocytes (gray hair), moisture, sweat and sebaceous glands.
b. Predisposing risk factors: exposure to ultraviolet (UV) rays (sunlight, excessive tanning); adverse medication effects; personal hygiene habits (too frequent bathing); limited activity, heredity.
c. Functional consequences: dry skin; skin wrinkles; delayed wound healing; increased— susceptibility to burns, injury, infection, altered thermoregulation, skin cancer, cracking nails.
- Nursing goal/implementation: treatment for pressure sores.
Stage I—reddened broken skin: cover and protect (use sprays, gels, transparent films, transparent occlusive wafers).
Stage II—blister or partial-thickness skin loss: cover, protect, hydrate, insulate, and absorb exudate (use transparent films, occlusive wafer dressings, calcium alginate for absorbing exudate; polyurethane foam, moistened gauze dressing).
Stage III—full-thickness skin loss: cover, protect, hydrate, insulate, absorb, cleanse, prevent infection, and promote granulation (use occlusive wafer dressings, absorption dressing, calcium alginate, and moistened gauze dressings).
Stage IV—full-thickness skin loss involving muscle, tendon, and bone: same as stage III except before promoting granulation, dead eschar (tissue) is removed (use absorption dressing, calcium alginate, and moistened gauze dressings).
F. Polypharmacy—concurrent use of several drugs increasing the potential for adverse reactions, drug interactions, and self-medication errors (Medications That Should Not Be Used by Geriatric Clients).
Reasons for polypharmacy:
a. Lack of communication among multiple health-care providers.
b. Lack of information about over-the-counter drug use.
c. Lack of information about client noncompliance.
d. Use of complementary (alternative, folk medicine) therapies and fear of telling health-care provider.
e. Assumption that, once medication is started, it should be continued indefinitely and not changed.
f. Assumption that, if there are no early side effects, there will not be any later.
g. Changes in daily habits (smoking, activity, diet/fluid intake).
h. Changes in mental-emotional status that may affect consumption patterns.
i. Changes in health status.
j. Financial limitations (drug substitution).
- Nursing goal/implementation: assist the older adult to use medications safely and try nonpharmacological interventions for common health problems.
a. Constipation: exercise, relaxation, biofeedback; increase fluid and fiber intake.
b. Stress incontinence: pelvic muscle exercises, biofeedback.
c. Anxiety, depression: counseling, exercise, meditation, relaxation techniques; touch, music, and pet therapy.
d. Arthritis: acupuncture, heat therapy, therapeutic exercise, postural or alignment aids; touch, music, and pet therapy.
e. Chronic neuromuscular problems: massage, body work, touch and music therapy.
f. Sleep problem
G. Hearing changes—external auditory canal atrophies, resulting in thinner walls and increased cerumen buildup; degenerative changes in ossicular joints leading to slower/stiffer movements; loss of hair cells and cochlear neurons in inner ear.
- Types:a. Presbycusis—bilateral loss of high-pitched tones; slightly less severe in women than in men.
b. Impaired pitch discrimination—after age 55, makes localizing and understanding sounds difficult; impaired ability to understand consonants.
c. Decline in speech discrimination—after age 60, speech intelligibility declines; slowing of memory and slowing of mental processes with advancing age may also affect speech, hearing, and understanding.
d. Diminished vestibular function—deficits in equilibrium and greater fall risk.
- Nursing goal/implementation: improve communication for person who is hearing impaired.a. Compensate with other senses—face listener; make eye contact if culturally acceptable; get person’s attention before talking; use touch if culturally appropriate; help with hearing aid; avoid walking around room while talking; write down key words if person can read.
b. Alter stimulus and behavior—speak in normal volume of voice or slightly lower, avoid shouting; use short sentences; separate important words with pauses; allow more time for communication; have person repeat to show
understanding; repeat; teach person to be more assertive about impairment.
c. Modify environment—eliminate or reduce background noise (turn off running water, close doors, lower TV or radio); select areas with sound-absorbing abilities (carpets, drapes) for conversations; amplify telephone; allow for adequate light on speaker’s face.
H. Visual impairment.
- Age-related macular degeneration (AMD)— leading cause of irreversible and legal blindness for those over 65 years; blurred far and near vision; loss of central vision; difficulty going up and down steps and stairs; parts of words and letters disappear when reading; straight lines appear to be wavy. Acuity: 20/200 or less.
a. Assessment. Risk factors: increased age, women, Caucasian, smoking, UV light exposure, diabetes, diet (low in leafy green vegetables and antioxidants).
b. Prevention: UV light filters, aspirin, vitamins A and B, beta-carotene, zinc.
c. Prognosis: no treatment or cure; laser may prevent spread of AMD in some clients.
d. Nursing goal: assist client to maintain independent functioning.
I. Loss of urinary control—neurological mechanism controlling bladder emptying does not work effectively and results in incontinence; a symptom, not a diagnosis.
- Assessment. Risk factors:
b. Cognitive and functional impairments— Parkinson’s disease, Alzheimer’s disease, multiple sclerosis, alcoholism, stroke, vitamin B deficiency, inability to walk and transfer to toilet.
e. Pathological conditions—men: hyperplasia leading to infection, incomplete emptying, urgency, and frequency; women: weakening of pelvic floor post-menopause, leading to residual urine and infection; atrophy of vaginal and trigonal tissue, leading to frequency, urgency, and incontinence.
- Incontinence—possible symptom of urinary tract infection (UTI), impaction, chronic constipation, dementia, inability to walk and transfer by self to toilet, dehydration.
- Nursing goal/implementation: minimize incontinence episodes and reduce urinary tract infections.
a. Regular toileting schedule—every 2 hours, with some exceptions at night; or personalize regimen based on assessment.
b. Modify environment—location of toilet, good lighting, prompt response to calls for assistance, use of Velcro closures on clothing, raised toilet seats with safety bars.
c. Monitor fluid intake; adequate hydration— 1 to 2 L during day; avoid alcohol and caffeine and restrict fluids at bedtime.
d. Avoid medications contributing to incontinence.
e. Avoid use of indwelling catheters if possible.
f. Use usual undergarments; be positive about continence; use absorbent pads to improve perineal hygiene if other measures fail.
g. Treat constipation.
h. Observe for signs of UTI.
J. Sexual neglect—many myths exist about sexuality and aging.
- Facts about sexuality in the older adult:
a. Sexual desire can and does exist in advanced age
b. If in good health, a satisfying sex life can extend into the 80s and beyond; if sexually active in youth and middle age, vigor and interest will be retained into old age.
c. Sexual attractiveness has little to do with age and the appearance of partner.
d. Less than 1% of sudden coronary deaths occur during sexual intercourse; greater anxiety and tension exists if sex is restricted.
e. Vaginal lubrication is decreased because of menopause, but sexual pleasure still exists.
f. Sex may actually be better in later years; partners have an appreciation of intimate sharing and caring.
g. Sexual activity is a good form of exercise and helps maintain flexibility and stamina.
h. Older adults have a strong interest in sexual activity and physical and mental well-being; older adults should be encouraged to continue sexual interests without guilt.
i. Male erections can continue into the 80s and beyond.
- Nursing goal: assist the client to reduce barriers to a satisfying sexual experience.
a. Barriers to a satisfying sexual experience:
(1)Loss of sexual responsiveness—causes: monotony of a “same old” sexual relationship; mental or physical fatigue; overindulgence in food or drink; preoccupation with career or economic pursuits; physical or mental infirmities of
either partner; performance anxiety; lack of privacy.
(2)Changes with aging—hormonal; decreased muscle tone and elasticity; prostate hyperplasia; sclerosing arteries and veins; increased time needed for arousal and rearousal; medications (e.g., antihypertensives); surgery (e.g., prostatectomy); response to menopause; availability of a partner.
K. Caregiver burden—80% to 90% of the care given to adults who are dependent is given by family and friends, especially middle-aged women.
- Negative consequences of care giving:
a. Infringement on privacy.
b. Decreased social contact.
c. Loss of income and assets.
d. Increased family conflict and distress.
e. Little or no time for personal or recreational activities.
f. Increased use of alcohol and psychotropic drugs.
g. Changes in living arrangements (sharing households).
h. Likelihood of decreasing or giving up job responsibilities.
i. Increased risk of clinical depression.
j. Feelings of anger, guilt, anxiety, grief, depression, helplessness, chronic fatigue, emotional exhaustion.
k. Poor health and increased stress-related illness and injuries.
- Positive consequences of care giving:
a. Family becomes closer.
b. Making a difference in the quality of care.
c. Companionship for adult who is dependent and caregiver.
d. Better understanding of the needs of the adult who is dependent.
e. Feeling useful and worthwhile.
f. Improved relationship between caregiver and adult who is dependent.
- Impact of hospitalization of older adult on caregiver:
a. Frustration with delays in older adult being admitted.
b. Perception of poor care; complaints about rudeness; upset that call lights and questions are not answered in a timely manner.
c. Lack of involvement in decision making.
d. Lack of preparation for discharge; too much information given too quickly; problems coordinating services (e.g., home visits, needed equipment).
e. Fatigue/stress from going back and forth to hospital.
- Nursing goal/implementation: assist the caregiver in achieving control and a sense of satisfaction.
a. Strategies to minimize caregiver burden:(1)Develop and maintain a routine.(2)Concentrate on the present.
(3)Talk about the reasons for being a caregiver.
(4)Use respite care as needed.
L. Poor nutrition.
- Assessment of warning signs:
a. Disease, illness, or chronic condition that changes eating habits/pattern; also emotional problems: confusion, depression, or sadness.
b. Eating too little or too much, skipping meals, drinking more than 1 to 2 alcoholic beverages daily.
c. Missing, loose, or rotten teeth, or ill-fitting dentures.
d. Spending less than 25 to 30 dollars per week on food.
e. Living alone.
f. Taking multiple medications with increased chance for side effects (change in taste, constipation, weakness, drowsiness, diarrhea, nausea).
g. Unplanned weight loss or gain.
h. Problems with self-care (walking, shopping, buying and preparing food).
i. Age greater than 80 (frail elderly).
- Nursing goal/implementation: promote optimal nutritional health for the older adult ( for additional information on nutrition in the older adult).
a. Encourage fluids during meals.
b. 5 to 6 small meals per day.
c. Advise not to lie down for 1 hour after a meal.
d. Avoid overuse of salt and sweets.
e. Use alternate seasonings: herbs, garlic, lemon.
IV. SUMMARY OF MOST FREQUENT ISSUES IN THE CARE OF THE OLDER GERIATRIC CLIENT (Most Frequent Issues in the Care of the Geriatric Client)
V. Use the functional rating scale for the geriatric client (Functional Rating Scale for the Geriatric Client) to rate social resources, economic resources, mental health, physical health, and activities of daily living.
VI. Use the functional screening examination (Functional Screening Examination)
to help determine dependent/independent status for planning home care.