Exam Flashcards
Medications for age related changes
-decreased body water
-decreased lean tissue
-increased body fat
-decreased albumin
-decreased liver and renal function
-decreased GFR (decreases renal clearance)
-decreased hepatic blood flow
-receptor sensitivity
risk factors for medications
-pathologic processes
-functional impairments
-polypharmacy
-inadequate monitoring
-financial barriers
-insufficient recognition of adverse effects
-inappropriate prescribing
-communication barriers
-lack of information
Changes That Affect the Action of Medications in the Body
-Age-related changes in body composition (i.e., decreased body water and lean tissue and increased body fat, decreased albumin, decreased liver and renal function).
-Medications that are distributed primarily in body water or lean body mass may reach higher serum concentrations and their effects may be more intense.
-Serum concentration of highly fat-soluble substances can increase, so the immediate therapeutic effects are diminished, but the overall effects are prolonged or erratic
STOPP/START
evidence-based screening tool of older persons’ prescriptions
Communication barriers
Older adults reluctant to challenge or question
Fear of appearing ignorant
Hearing and vision impairments
Attitude of impatience on part of health professionals
Language barriers
prescribing cascade
adverse drug reaction mistaken as new medical condition
Medications and Nutrients
-Changes in the gastrointestinal tract can delay or diminish the absorption of medications.
-Medication interactions are likely to occur if the following medications are taken with food: biphosphonates, carbidopa/levodopa (Sinemet), ciproflocacin (Cipro), digoxin (Lanoxin), furosemide (Lasix), glipizide (Glocotrol), levothyroxixin (Synthroid), metformin (Glucophage), metoprolol (Lopressor) and warfarin
medications and alcohol
-Central nervous system depression
-Health care providers often do not accurately assess an older adult’s alcohol consumption.
-Alcohol can alter the therapeutic action of medications and increase the potential for adverse effect
-Over-the-counter preparations may have alcohol as an ingredient.
More susceptible to interactions between alcohol and medications
medications and nicotine
-Associated with tobacco smoking, smokeless tobacco and other nicotine-based products
-Affects therapeutic action of the medication
-Smokers may require higher doses of a medication
-Dosages of medications may need adjustment.
Functional Consequences Associated with Medications in Older Adults
-Altered Therapeutic Effects
-medications need to be monitored more closely in older adults, especially initially and when there is any change in the person’s medical status or treatment regimen
“start low and go slow.”
-Increased Potential for Adverse Effects
-Decline in function, an increased risk for falls and fractures, an increased number of visits for health care services, admission to a hospital or prolongation of a hospital stay
-Anticholinergic Adverse Effects
-Altered Mental Status
-Delirium
Common types of medications with anticholinergic properties
antidepressants, antihistamines, antiparkinson agents, antipsychotics, cardiovascular agents, gastrointestinal agents and urinary antispasmodics
Antipsychotics in People With Dementia
Extrapyramidal side effects, anticholinergic side effects = risks of orthostatic hypotension and falls
tardive dyskinesia
Rhythmic and involuntary movements of the trunk, extremities, jaw, lips, mouth or tongue.
The earliest signs are usually fine, wormlike movements of the tongue.
Other early signs include chewing, grimacing, lip smacking, jaw clenching, eye blinking and side-to-side jaw movements.
Manifestations can begin as early as 3 to 6 months after initiation of antipsychotic medications, and they usually persist even after the causative agent is discontinued.
It is considered an adverse effect of dopamine receptor-blocking agents and serotonin-norepinephrine reuptake inhibitors (i.e., certain antipsychotics and antidepressants)
Tardive dyskinesia deserves special attention with regard to older adults because advanced age correlates with both an earlier onset and increased severity of tardive dyskinesia.
drug induced Parkinsonism
Parkinson-like manifestations.
Manifestations can be reversed if the offending drug is stopped
The condition is often misdiagnosed as Parkinson disease and treated inappropriately with an antiparkinson medication.
Main causative drugs identified in studies include antipsychotics, calcium-channel antagonists, valproic acid and antiepileptic agents
Factors that Increase the Risk for Adverse Medication Effects
Increased numbers of medications
Frailty
Malnourishment or dehydration
Multiple illnesses
An illness that interferes with cardiac, renal or hepatic function
Cognitive impairment
History of medication allergies or adverse effects
Recent change in health or functional status
Medications in any of the following categories: anticoagulant/antiplatelet, antidiabetics, NSAIDs, central nervous system drugs
Barriers to nursing assessment of medications
time limitations
complex medication regimens
lack of a trusting relationship
Scope of medication assessment
All medications and other bioactive substances used
Individual’s understanding of medications
Allergies and adverse reactions
Perception and preferences
Cultural factors influencing medication use
Sources of health care
Observing patterns of medications used
-Ask to see all medications used or have them bring all medication to appointment (both prescription and over-the-counter medications).
-Direct observation of medication containers
Linking the medication assessment to the overall assessment
-Past and present medications: Help identify health issues.
-Identify clues to problems or complaints.
-Assess for residual adverse effects.
-Expected versus actual outcomes of medication interventions
-Functional ability to take medications
-Assessment of the living environment
-Risks for nonadherence
Nursing Interventions to Promote Safe and Effective Medication Management
Medication reconciliation
Teaching about medications and herbs
Addressing factors that affect adherence
Decreasing the number of medications
nociceptive pain
-Physiologic process leads to perception of noxious stimulus as painful
-Way of signaling that something is wrong.
-Caused by tissue damage
-Often localized to the area where damage or injury has occurred.
-Four processes: transduction, transmission, perception and modulation
neuropathic pain
-Caused from damage or dysfunction of nervous system.
-Unlike nociceptive pain, which is typically caused by tissue damage , neuropathic pain is often due to abnormalities in the nerves themselves.
-Abnormal processing of sensory stimuli by central or peripheral nervous system
-Can occur in the absence of immediate tissue damage or inflammation
acute pain
-Sharp, immediate pain from injury to tissue
-Time limited and responsive to analgesic
persistent pain
-lasts longer than 3 to 6 months or beyond the expected time of healing
-Continues for prolonged period; may or may not be associated with a recognizable disease process
cancer pain
-Complex phenomenon caused by cancer itself
-Can be acute, persistent, nociceptive, neuropathic or a combination of these types
-Caused directly by cancer and indirectly by the effect of cancer
Functional Consequences of Pain
Diminished physical function
Psychosocial effects
Sleep disturbances
Weight loss
Increased dependency
Decreased quality of life
Social isolation
causes of pain in older adults
Widespread problem for older adults
Chronic conditions and diseases of older adults
Arthritis pain
Postherpetic neuralgia
Back problems
Fibromyalgia
Diabetic peripheral neuropathy
cultural aspects of pain
-Cultural factors: influence the way people experience, express and manage pain
-Awareness of cultural differences of expression
-Avoid stereotyping.
-Recognize actual and potential influences of personal biases, attitudes, experiences, misconceptions and lack of information.
Vulnerable Populations for Pain to be Undertreated
-65 or older
-Racial and ethnic minorities
-Women
-Low health literacy, low english proficiency (recent immigrants)
-Lower income and level of education
-Older adults commonly fear negative consequences of analgesia (ie. addiction)
Obtaining information about pain
-Assess for pain during initial contact, at frequent intervals, when condition changes.
-Assess effectiveness of analgesic 30 to 60 minutes post-administration.
-“Gold standard”: self-report about pain
-Pain rating scales used to assess pain intensity
-Use open-ended questions to identify person’s expectation for relief.
Pain assessment tools
The Pain Assessment in Advanced Dementia
Pain Assessment Checklist for Seniors with Limited Ability to Communicate
Adjuvant analgesics
-medications that have a primary indication other than the treatment of pain, such as antidepressants or anticonvulsants, but relieve pain in some conditions.
-Adjuvants most often act on the modulation phase along the pain pathway by interfering with the reuptake of serotonin and norepinephrine, thereby inhibiting the transmission of nociceptive impulses
Health Assessment of Older Adults
-Manifestations of illness, even acute illness, tend to be less predictable in older adults than in younger adults.
-For any one manifestation of illness in an older adult, there are usually several possible explanations
-Cognitive impairments can make it difficult for older adults to accurately report or describe a physiologic problem and reliable sources of information may be scarce or inaccessible.
Lab Values that are NOT affected by Normal Aging
Hematocrit and hemoglobin
Electrolytes (sodium, potassium, chloride, bicarbonate)
Calcium
Phosphorus
Liver function tests
Blood urea nitrogen
Thyroid tests
White blood cell count
Platelet count
Lab Values that are often abnormal in older adults
Glucose
Albumin
Serum iron, iron-binding capacity, ferritin
Alkaline phosphatase
Try This: Best Practices in Nursing Care of Older Adults
-Cost-free web-based articles and videos
-Identify specific areas to address in care plan
-Identify conditions that affect health status, level of functioning and quality of life
RNAO (Registered Nurses’ Association of Ontario)
Best Practice Guidelines have been developed for “Screening for Delirium, Dementia and Depression in the Older Adult,” as well as “Caregiving Strategies for Older Adults with Delirium, Dementia and Depression,” “Prevention of Constipation in the Older Adult Population” and “Prevention of Falls and Fall Injuries in the Older Adult.”
NICE (The National Initiative for the Care of the Elderly)
provides tools for nurses for assessment of older clients pertaining to walking, elder abuse, driving cessation, mental health
SPICES
Sleep disorders
Problems with eating or feeding
Incontinence
Confusion
Evidence of falls
Skin breakdown
SHOW ME
Shirt & shoes
Hike to bathroom
Organization
Walk through home in all areas needed for ADL/IADL, Medications
Eating and making meals
*Used to assess level of functioning
functional assessment
Measurement of person’s ability to fulfill responsibilities and perform self-care tasks
-In geriatric clinical settings, there is increasing emphasis on using functional assessments as a core component of function-focused care, which is a rehabilitative approach to preventing functional decline and improving an older adult’s level of functioning
-Use of open-ended questions
ADLs
bathing, dressing, mouth care, hair care, dietary intake, transfer mobility, ambulation, bed mobility and bladder and bowel elimination.
IADLs
shopping, laundry, transportation, housekeeping, meal preparation, money management, medication management and the use of telephone.
assess functioning in older adults with cognitive impairment
Cleveland scale for activities of daily living
function focused care
-previously referred to as restorative care
-Focus on evaluation capability in regard to functional and physical activity with interventions to optimize and maintain functional abilities and increase physical activities
-rehabilitative approach to preventing functional decline and improving an older adult’s level of functioning
Comprehensive geriatric assessment
medical
psychosocial
cognitive
functional components
minimum data set (MDS)
-standardized assessment form for nursing homes
-done on admission and every 3 months
-Primary purpose: to improve care and quality of life of older adults
