Exam 1 Flashcards
Describe why clinical decision making=complex in older adults
-Vague s/s w/ illness
-Tendency to disregard as “normal” in aging
-don’t complain due to concern of being a burden
-communication deficits
-multifaceted conditions
what are the geriatric syndromes?
IFFCUPD
Immobility, frailty, falls, constipation, urinary incontinence, polypharmacy, delirium
Difference between IADL’s and ADL’s
IADL= physical and cognitive performance required, first to go, higher LOC and ability needed
ADL= last to go, self care activities
Examples of ADL’s
Brushing teeth, bathing, toileting, dressing
Examples of IADL’s
Grocery shopping, managing finances/medications, housekeeping
How does the loss of ADL’s affect an older adult’s care?
It increases their dependence, which can lead to a decline in autonomy and condition
How does the loss of IADL’s affect an older adult’s care?
Loss of autonomy, independence
Normal aging changes for older adults
Decline in speed, decrease in stride, slower bowel sounds, decreased appetite/thirst, kidney function decreases, decreased bladder capacity, high frequency hearing loss, breathing capacity decreases, gray hair and wrinkles, decreased skin elasticity and strength, body fat increases in trunk
Abnormal aging changes for older adults
TUG of 12 or greater, anxiety/depression, malnutrition (dysphagia), insomnia, hypersomnia, pressure ulcers, falls, delirium
Interventions to prevent/decrease fall risks
Ensure clutter free environment, good walking shoes, proper use of assistive devices, evaluate meds for adverse effects causing immobility, treat and manage conditions causing immobility (PT)
Describe get up and go test (TUG)
Have a pt sit in a chair, stand up, walk forward 10 feet, turn around, walk back to the chair, and sit down again. This must happen in less than 12 sec. Observe gait, stride, postural stability, sway, and balance
What does it mean if a client cannot complete the TUG in less than 12 sec?
Higher risk for falling
What are the types of gaits?
Hemiplegic, parkinsonian, cerebellar/ataxic, stomping/stamping, diplegic/CP, myopathic/“waddling“, neuropathic/“steppage”, choreiform
Choreiform gait
Writhing movements, random involuntary
Steppage/neuropathic gait
Equine gait, can’t step forward without tripping because dorsi flex=weak, so have to bring knee up high and kick leg out
Stomping/stamping gait
Lack of proprioception- relies on visual cues to know that foot has hit the floor. Stomps for vibrations to be obvious through the foot, more prominent in the dark
myopathic/“waddling” gait
Pelvis not stable to bear weight when taking step-lean trunk to compensate to other side-waddling gait
Diplegic/CP gait
Extensor spasm, walking in tip toes, some circumduction and a abductor spasm keeping feet close together, arms flexed, scissors gait
Parkinsonian gait
General flexion(every joint), small shuffles, tremor associated with gait
Cerebellar gait
Broad stance, wide staggering falling forward and to one direction, trunk sways when standing still
hemiplegic gait
Hand flexed to chest(may not be if mild), unilateral circumduction of foot when walking forward, arms do not both swing/ arm does not swing normally. Flexion and extensor hypertonia, foot drop
How does immobility affect overall levels of care (older adult)
Unable to care for self, relies on family/support (a lot of pressure/burnout), loss of independence, refusal to accept need help, adherence= low, poor outcomes=high
Factors to consider when assessing the home for falls
Rugs, lights, handrails, pets (running around/under feet), alone?, appropriate footwear, gait change, activity level
Constipation
“Infrequent, incomplete, or painful evacuation of feces for three days or more”
Medications to help manage constipation
Hyperosmolar agents, prokinetic agents(not recommended for elderly)
Polyethylene glycol class
Hyperosmolar agent, non addictive
Stool softeners
Colace, docusate sodium
When to take a laxative
Last resort- do not want to use stimulants first, do not want to become dependent. Hypoactive bowel sounds, no BM within 3 days
Water intake and its role in constipation
Inc water=dec constipation, absorbs into feces, softening form; inc fluid in colon leads to inc in peristalsis
Stimulant (constipation)
GoLytely, Bisacodyl, Senna
Stimulates intestinal peristalsis and inc volume of water&electrolytes in intestines
Polyethylene glycol
Miralax, osmotic that draws water into intestine to inc mass of stool=peristalsis, contraindicated in HF and Bowel obstruction
Stool softener
Docusate sodium, colace
Lowers surface tension of stool to allow water in, typically for softening fecal impact ion
Management of Urge incontinence
Initial: Kegels/PFT
Treat UTI, atrophic vaginitis, meds to reduce tone of bladder, scheduled voiding for pts with cognitive deficits
Management of stress incontinence
Kegels/PFT
-tx atrophic vaginitis
-insertion of pessary
-toileting/fluid regimen
-surgery- A&P repair, bladder sling
Management of overflow bladder incontinence
Med review
-bladder retraining
-reverse cause
Improve glucose readings, reduce ETOH, catheterization
Management of functional incontinence
Remove barriers for BR use
Pictures on BR door
Improve mobility with PT/OT
Meds to reduce tone of bladder- Urge incontinence
Tricyclic agents- Imipramine
Tolterodine, darifenacin, solifenacin, oxybutynin
Scheduled voiding for pts with cognitive deficits
What are the concerns for oxybutynin for older adult?
Vasodilation(spasticity med, relaxes muscles)- orthostatic hypotension
Kegels/pelvic floor
Most notice positive change after 6 weeks, 10 times daily, tighten pelvic muscle for 10 sec then release-do this 15X (lying,sitting, standing)
Oxybutynin
Medication for BPH and overactive bladder w/ urge frequency/incontinence; decreases detrusor muscle contractions
Topical estrogen
Hormone
Tx for overactive bladder, atrophic vaginitis, stress incontinenece
Why do older adults become acutely confused and how do we recognize and intervene appropriately?
Infection, medication change, trauma (hospital stressors), surgeries=#1
-short term and reversible
Assess with CAM
How to administer CAM
Confusion assessment method
1. Acute onset form baseline
2a. Inattention
2b. If present, did it fluctuate?
3. Disorganized thinking (rambling, incoherent, unpredictable)
4. Altered LOC(alert,lethargic, vigilant, coma)
5. Disorientation
6. Memory impair
7. Perceptually disturbed (hallucinations and illusions)
8a. Psychomotor agitation (inc level of motor activity, restlessness,picking)
8b. Psychomotor retardation (dec level of motor activity, sluggish/slow moving, staring into space)
9. Altered sleep/wake
What makes the CAM positive
Presence of 1 and 2 and either 3 or 4
Interventions for delirium
Resolve cause if possible (treat infection, rehydrate, reorient, keep awake during day to sleep at night to reset sleep cycle)
-start low and go slow with medications, encourage family members to be there (easier to reorient)
Polypharmacy
When a pt is on multiple medicines- or more of the same meds in diff forms- and on more than clinically needed
Beer’s list
list of medications not safe for older adults
>81mg aspirin, dabigatran (inc risk bleeding), drugs that eliminate through kidney, drugs with high first pass effect, drugs with low therapeutic ranges
-Anticholinergics, opioids, antihistamines
Ways to decrease problems of multiple drugs
Med rec
What classes of drugs were mentioned in class as a major problem for older adults
Anticholinergics, narcotics, antihistamines
Specific drugs mentioned in class as major problems for older adults
Anticholinergics
Opioids
Antihistamines
Issues with safe drug therapy for older adults
Routine adherence, remembering if they took them or not, understanding dosages/ timing, obtaining refills, polypharmacy
Interactions of normal aging and responses to drug therapy in older people
smaller therapeutic index, metabolism=slower–> takes less amt of drug for a therapeutic response. start low and go slow
Frailty
Progressive physiological decline of multiple Body systems
Causes: older adult w/ chronic illness, loss of organ function, poverty, social isolation
3,2,1 Method
Assessment for frailty; how to assess when there isn’t a “tool”
Presence of 3 or more co-morbid conditions, needs assistance with 2 ADL’s, Dx of one geriatric syndrome
Assess ADL’s and IADL’s, nutrition, and fall risk
Co-morbid conditions criteria for frailty-LUWEPS
-Unplanned weight loss
-Exhaustion
-Weakness
-Poor endurance
-Slowness
-Low levels of physical -activity
Acronyms for frailty
SPICES and PULSES
SPICES- frailty
S-sleep disorders
P- problems with eating
I- incontinence
C- Confusion
E- Evidence of falls
S- skin breakdown
PULSES-frailty
P-physical condition
U-Upper limb function
L-lower limb function
S- sensory components
E-excretory components
S-support factors
P for Physical
Factors of frailty
Dependency, injury, institutionalization, falls, hospitalization, rapid decline, mortality
Impact of chronic disease for older adults
Prevention=important
Once disease occurs-focus:
-Managing s/s
-avoiding complications
-avoiding acute illness
-promoting health
-maintaining functional status
-psychological adjustments to physically accommodate disabilities
-social isolation
Assessment of pts with chronic diseases
-Identify specific problems
-Establish/priortize goals
- define plan of action to achieve desired outcome
-implement plan: adhere to regimens, keep illness stable, psychosocial issues
-follow up,evaluate outcomes
Characteristics of chronic disease
Med conditions/health problems w/ associated s/s—>long term management
-conditions that do not resolve or for which complete cures are rare
-managing chronic illness involves more than treating med problems
-diff phases over person’s lifetime that they must adapt to
-persistent adherence to therapeutic regimens
-one chronic disease can lead to another developing
-effect more than just pt
-self-management required
most important intervention for chronic illnesses in older adults
Prevention!
Diet, exercise (150minweek), no smoking, alcohol use effects physical and emotiona
Once chronic illness occurs in older adult…
Managing s/s, avoiding complications, avoiding acute illness, promoting health, maintaining functional status
Health literacy principles for older adults
Assess knowledge by asking them to explain their condition/ medication purpose
Ask about their perspective of illness/condition
Clear communication with explanation
Most common s/s UTI older adults
Confusion, delirium, falls, sudden onset, fever, tachycardia, hypotension
Nursing interventions to reduce reoccurrence older adult UTI
-Drink 2-3L fluids/day
-encourage rest and nutrition
-clean front to back
-avoid douches, scented lube, bubble baths, tight-fitting underwear, scented toilet paper
-empty bladder before and after intercourse
-do not delay urination
-cranberry juice/supplements
Benign prostatic Hyperplasia
Enlarged prostate, obstructs urethra and urine flow; overflow incontinence; if persists, urine backflow in ureters and kidneys-kidney damage
Risk factors for Benign Prostatic Hyperplasia BPH
-Increase in age (men >80 yrs)
-smoking, chronic alcohol use
-sedentary lifestyle, obesity
-high fat, protein, carb diet, low fiber
-DM, CV disease
Expected findings for BPH
Straining to urinate
Hesitancy
Dec force of stream
Frequency
Incomplete emptying
Dribbling
Urgency
Hematuria
Nocturia (“most difficult symptom”)—> why most seek tx
-cannot start urine flow or maintain stream
Lab tests and other diagnostics for BPH
PSA- rule out prostate cancer(elevated=cancer)
DRE- reveal enlarged, smooth prostate
UA- WBCs and bacteria
CBC- RBC count
BUN/creatinine- elevated=kidney damage
Transrectal US w/ needle aspiration
Medications to re-establish uninhibited urine flow
Tamsulosin/Flomax, Terazosin/Hytrin, Finasteride, Sildenafil, saw palmetto
Alpha-blocking agents for establishing uninhibited urine flow
Tamsulosin, Terazosin(Hytrin)
Hytrin
Dec. Smooth muscle tone, relaxation of bladder and prostate gland
Complications=hypotension , dec/failed ejaculate
-Contraindicated in liver and renal impairment ; should not be used before cataract surgery
Tamsulosin
Dec smooth muscle tone (non selective=vasodilation)
- Complications=hypotension, dec/failed ejaculate
-Contraindicated in liver and renal impairment
-30 min after meal, same time each day
-monitor LOC and BP
should not be used before cataract surgery
3 way foley irrigation (BPH)
Ensure continuous flow, no kinks in tubing. TURP—> hemorrhage=biggest risk to evaluate for
Monitor for blood and clots-> bleeding bladder spasms=bleeding, trying to clot
Bleeding=irrigation to prevent blockage from clots
Non-pharmacological interventions for BPH
Limit caffeine ETOH, table salt, spicy foods, fluids after dinner
-reg voiding schedule
- lose weight, inc exercise
When is drug therapy started for BPH?
S/s affect QOL or significant outlet obstruction present (Tamsulosin=safer)
-prevent permanent bladder dysfunction and renal insufficiency
What are the concerns r/t nutrition in older adult?
Low sodium, dec absorption of mult vitamins, inc risk for osteoporosis, dec lean muscle mass, caloric intake, weight loss, malnutrition, dehydration
Interventions to help w/ older adult appetite?
List foods they enjoy, flavored with salt or sweet
What labs do we use to monitor the older adult’s nutrition?
CMP, BMP,CBC
Hallmark symptoms- Parkinson’s disease
Tremor, Parkinsonian gait(shuffling steps, flexed joints, tremor), stooped posture, forward tilt of trunk, mask-like face, drooling, rigidity, pill roll tremor, bradykinesia
How/when do Parkinson’s disease s/s present?
Early 60s-80s
Progression over 20 years
What gaits are present? (Parkinson’s)
parkinsonian (propulsive) gait, bradykinesia, freeze periods
How does gait and s/s affect the PD patient’s QOL?
Decrease in independence, mobility, and functionality—> overall health decline
Major concerns with caring for the PD patient in all stages of the disease
Safety, medication adherence/education, independence, nutrition, frailty
Interventions that the nurse should use for caring for Parkinson’s pts
-Daily exercise, ROM, postural exercise
-Warm baths
-Environmental modifications for self care
-Inc fluids, moderate fiber foods, regular bowel program
-monitor weight, extra feedings, high calorie, high protein diet
-monitor skin (inc risk for melanoma)
-family teaching
Challenges with medication management (Parkinson’s)
Levodopa- more side effects over time- side effects
Sinemet/Parcopa(levodopa-carbidopa)-cant eat within 2 hrs
Protein heavy meals limits drug absorption and utilization
Best absorbed on empty stomach (1 hr before OR 2 hrs after)
Medication Classes (Parkinson’s)
Anticholinergics(artane, Cogentin)
Dopamine Agonists
Catechol-O-Methyltransfrese (COMT) Inhibitors
Dopamine replacement/ enhancement drugs (Parkinson’s)
Levodopa, Sinemet/Parcopa (Levodopa & Carbidopa Combined)
Used BEFORE or WITH Levodopa
High risk of hypotension and dec LOC
“Rescue” drug for off times
COMT inhibitors (Parkinson’s)
Inc duration of Sinemet-blocks enzyme breaks down levodopa
NO effect on PD symptoms ALONE
N/hypotension=S/E
entacapone, tolcapone
Interventions to decrease postural hypotension
Ankle pumps, HOB elevated, dec contributing medications, pressure stockings, teaching pt to get up/change position slowly
Artane/Cogentin
anticholinergic
Help control tremor and rigidity by counteracting acetylcholine (blocks cholinergic receptors)
Very risky- urinary retention, dry mouth, blurred vision, constipation
What is the ARMOR scale?
Used on LTC pt, improve med adherence and reduce ADEs (adverse drug events)
ARMOR
Assess, Review, Minimize, Optimize, Reassess
What is the A in armor?
Assess:
What meds they are on
R in ARMOR
Review:
Drug-drug, drug-disease, and adverse drug reactions
M in ARMOR
Minimize:
Number of meds according to functional status rather than evidence-based medicine
O in ARMOR
Optimize:
For renal/hepatic clearance,PT/PTT,etc
Second R in ARMOR?
Reassess:
Functional/cognitive status in 1 week and as needed
-clinical status and medication compliance
Finasteride
dec the breakdown of testosterone->shrinks prostate (Tx for BPH)
S/E: dec libido, gynecomastia, impotence, ORTHOSTATIC HYPOTENSION, caution with liver disease pts
Tamsulosin
alpha blocker
Relaxes smooth muscles
S/E: hypotension, dizziness, nasal congestion, sleepiness, faintness, problems with ejaculation, floppy iris syndrome
Contraindicated in severe liver failure
Take after meals
