Exam 2: Gero Lecture 5

Question 1

dry cracked itchy skin. inadequate fluid intake worsens. use super-fatted soaps and cleansers

Answer 1

xerosis

Question 2

itchy skin. a symptom not a diagnosis. may be r/t med side effects or secondary to disease. a threat to skin integrity.

Answer 2

pruritis

Question 3

thin fragile skin – extravasation of blood into surrounding tissue. wear long sleeves and protect from trauma.

Answer 3

purpura

Question 4

precancerous skin lesion. from sun exposure. derm visits every 6-12 months to monitor and treat

Answer 4

actinic keratosis

Question 5

waxy, raised, “stuck on” appearance, benign lesion. almost ALL older adults over 65 y/o

Answer 5

seborrheic keratosis

Question 6

painful vesicular rash over a dermatome, get vaccine at age 60

Answer 6

herpes zoster

Question 7

yeast infection, often in skin folds. keep skin clean and dry

Answer 7

candidiasis

Question 8

where are the highest incidences reported for pressure injuries?

Answer 8

hospitalized or institutionalized older adults and vulnerable adults undergoing orthopedic procedures

Question 9

can significantly impair recovery/rehab and impact QOL. increased risk for mortality, high prevalence of health care litigation.

Answer 9

pressure injury

Question 10

CMS now considers pressure ulcers a __________________ adverse event and do NOT reimburse treatment for pressure ulcers acquired during admission.

Answer 10

preventable

Question 11

key factor in maintaining health =
important factor in delaying onset and managing chronic illness =

Answer 11

adequate nutrition
adequate diet

Question 12

what does proper nutrition include?

Answer 12

carbohydrates – 45-65%
fat – 20-35%
protein – 10-35%
vitamins and minerals – 5 servings of fruit and veggies

Question 13

what is overweight BMI?

Answer 13

25-29.9

Question 14

what is obese BMI?

Answer 14

30-39.9

Question 15

what is morbid obese BMI?

Answer 15

40+

Question 16

1/3 of 65+ are obese, the majority are…

Answer 16

women

Question 17

a geriatric syndrome, rising incidence in acute care, LTCF, and in the community. institutionalized older adults are at high risk due to chronic disease and functional impairments. comprehensive screening and assessment is critical to identify older adults at risk.

Answer 17

malnutrition

Question 18

increased risk of what in malnutrition?

Answer 18

infection
pressure ulcers
anemia
hip fractures
hypotension
impaired cognition
increased morbidity and mortality

Question 19

difficulty swallowing, about 20% of those over 50 y/o, and up to 60% of LTC residents.

Answer 19

dysphagia

Question 20

dysphagia risk factors?

Answer 20

cerebrovascular accident
Parkinson’s disease
neuromuscular disorder (als, ms, etc.)
dementia
head and neck cancer
traumatic brain injury
aspiration pneumonia
inadequate feeding technique
poor dentition

Question 21

dysphagia symptoms?

Answer 21

difficult labored swallow
drooling
copious oral secretions
coughing choking at meals
holding or pocketing food or liquids in mouth
difficulty moving food or liquids from mouth to throat
difficulty chewing
nasal voice or hoarseness
wet gurgling voice
excessive throat clearing
food or liquid leaking from nose
prolonged eating time
pain with swallowing
unusual head or neck posturing
sensation of something stuck in throat
heartburn
chest pain
hiccups
weight loss
frequent respiratory tract infections,
–> pneumonia

Question 21

dysphagia symptoms?

Answer 21

difficult labored swallow
drooling
copious oral secretions
coughing choking at meals
holding or pocketing food or liquids in mouth
difficulty moving food or liquids from mouth to throat
difficulty chewing
nasal voice or hoarseness
wet gurgling voice
excessive throat clearing
food or liquid leaking from nose
prolonged eating time
pain with swallowing
unusual head or neck posturing
sensation of something stuck in throat
heartburn
chest pain
hiccups
weight loss
frequent respiratory tract infections,
–> pneumonia

Question 22

dysphagia prevention of aspiration

Answer 22

supervise all meals
seated and rested before eating
sitting up at 90 degrees
dont rush meals
alternate solids and liquids
chin-tuck swallow
thickened liquids and pureed foods
avoid sedatives – may impair cough reflex
keep suction readily available
oral care

Question 23

PEG tubes in advanced dementia myths?

Answer 23

prevent death from inadequate intake
reduce aspiration pneumonia
improve nutritional status
provide comfort at end of life

Question 24

PEG tubes in advanced dementia FACTS?

Answer 24

do not improve QOL do not prolong survival in dementia associated with increased agitation, use of restraints, and worsening pressure injuries 50% of pt die within 6 months of insertion are associated with infection, GI symptoms and abscesses are popular r/t convenience and labor cost

Question 25

adequate fluid consumption and maintenance of fluid balance essential to health

Answer 25

hydration

Question 26

what are risk factors for changes in fluid balance?

Answer 26

Physiological changes in body water content Impaired thirst sensation Medications Functional impairments Chronic illness Emotional illness High environmental temperatures

Question 27

what are reasons why dehydration risk increases with age?

Answer 27

water/body ratio decreases, making you more susceptible to dehydration requiring the need of daily care as we are less able to handle day-to-day task needing assistance with food and fluid can significantly reduce self-hydration increase incontinence results in the need to replenish our fluids more often cog impair can mean that we may forget to keep ourselves hydrated with increased age brings diminished thirst sense the need of multiple meds can increase the onset of dehydration increase likelihood of acute illness, can result in out body being dehydrated

Question 28

What are the dehydration categories?

Answer 28

can drink can't drink won't drink end of life

Question 29

can drink =

Answer 29

able to drink may not know whats adequate possible cog impair encourage and make fluids accessible

Question 30

can't drink =

Answer 30

physical incapable to ingest or accessing fluids dysphagia prevention swallow evaluation safe drinking techniques

Question 31

won't drink =

Answer 31

highest risk for dehydration able to drink but refuses offer frequently prevent incontinence

Question 32

end of life =

Answer 32

terminally ill could be any of the previous 3 refer to advanced directives with regard to hydration wishes

Question 33

what are signs of dehydration?

Answer 33

skin turgor (unreliable r/t skin changes) weight mucous membranes speech changes tachycardia decreased UOP dark urine weakness dry axilla sunken eyes many of these signs are often unreliable in older people... LOOK AT BIG PICTURE (aka the pt)

Question 34

How is dehydration generally confirmed?

Answer 34

lab testing

Question 35

What are hydration interventions?

Answer 35

at least 1500 mL/day (2-3 L) water is best offer often make readily available encourage with meds provide preferred fluids verbal reminders

Question 36

what is urinary incontinence?

Answer 36

urge, stress, functional

Question 37

What are urinary incontinence interventions?

Answer 37

scheduled and prompted voiding pelvic floor muscle exercises (kegals) thorough assessment of continence lifestyle modifications meds urinary cath --> last resort

Question 38

What meds can worsen UIs?

Answer 38

meds with anticholinergic properties and diuretics

Question 39

What is the most common cause of sepsis in older adults?

Answer 39

UTIs

Question 40

often asymptomatic, cog impaired may not report symptoms, and normal for older adults to be asymptomatic, uncomplicated bacteria in urine.

Answer 40

UTI

Question 40

often asymptomatic, cog impaired may not report symptoms, and normal for older adults to be asymptomatic, uncomplicated bacteria in urine.

Answer 40

UTI

Question 41

what are atypical symptoms with UTIs?

Answer 41

mental status changes decreased appetite incontinence

Question 42

reduction in BM freq or difficulty in forming or passing stools. 40% older adults experience (more common in women)

Answer 42

constipation

Question 43

what are complications of constipation?

Answer 43

impaction obstruction cog dysfunction delirium falls increased morbidity and mortality increased risk for bowel cancer

Question 44

Age related bowel changes: small intestine

Answer 44

villi become broader, shorter, and less functional; blood flow decreases. proteins fats mineral (including Ca+), vitamins (vitamin B12), and carbohydrates (lactose) are absorbed more slowly in lesser amounts.

Question 45

What are constipation interventions?

Answer 45

increase physical activity = increases motility proper positioning = squat, lean forward toileting regimen = normalizes bowel function, attempt BM after breakfast or dinner (gastrocolic reflex) and allow at least 10 M for a BM increase fluid intake = at least 1.5 L per day increase dietary fiber = know foods high in fiber

Question 46

bulk-forming (fiber)

Answer 46

psyllium (metamucil)

Question 47

emollients

Answer 47

docusate sodium

Question 48

osmotic

Answer 48

polyethylene glycol (PEG), milk of magnesia, lactulose

Question 49

stimulant

Answer 49

bisacodyl, senna

Question 50

enemas:

Answer 50

last resort don't use on regular basis may alter fluid and electrolyte status sodium phosphate enemas contraindicated in older

Question 51

bulk forming (psyllium, methylcellulose)

Answer 51

usually 1st line agents due to low cost and few AE do not use in presence of obstruction or compromised peristaltic activity use with caution in frail older adults, bed bound, those with swallowing probs must be taken with adequate fluid intake to avoid obstruction in esophagus, stomach, intestines can cause abdominal distension and flatulence

Question 52

emollients and lubes (docusate sodium and mineral oil)

Answer 52

increase moisture content of stool insufficient evidence to recommend docusate for prevention or treatment of constipation; may alleviate straining in selected pts who undergo rectal surgery or had myocardial infarction use with caution in frail older adult who may not have the strength to push when having a BM since soft stool can accumulate in rectal vault the emollient laxative mineral oil should be avoided bc of risk of lipoid aspiration pneumonia

Question 53

osmotic laxatives (milk of mag, lactulose sorbitol, polyethylene glycol (PEG, miralax)

Answer 53

cause h2o retention in the colon avoid MOM in pts with renal insufficiency since use can lead to hypermag or hyperphosphatemia lactulose and sorbitol can cause diarrhea, abd cramps, flatulence MiraLax associated with less bloating and flatulence these meds can be added if bulk laxatives are ineffective

Question 54

stimulant laxatives (senna, bisacodyl)

Answer 54

stimulate colorectal motor activity may cause cramps and electrolyte or fluid losses but when used appropriately, they are safe and effective option, especially in those with opioid induced constipation

Question 55

complication of constipation, common in incapacitated and those in institutions (increased incidence with narcotics)

Answer 55

fecal impaction

Question 56

what are CM and complications of fecal impaction?

Answer 56

malaise urinary retention increased temp incontinence cog decline hemorrhoids intestinal obstruction

Question 57

what is the nursing management for fecal impactions?

Answer 57

first prevent! removal of impaction --> digital removal of hard stool from rectum, use copious lube, may take several days, don't disimpact too much, often very painful

Question 58

What are the sleep stages?

Answer 58

NREM 75% of night --> stages 1-4 REM 25% of night most changes in sleep begin >50 y/o less time in stage 3-4 (stage 3-4 = feeling rested and refreshed) more time awake or stage 1 REM critical for elders -- brain replenishment

Question 59

Sleep --> aging associated with:

Answer 59

Decreased sleep efficiency & total time Sleep disorders Circadian rhythm responses diminished Increase in stage one of sleep – less REM Longer to fall asleep Frequent awakenings Increased napping during day Frequency of leg movement increased

Question 60

age related changes in the body perception of light-dark cycles and circadian sleep wake rhythm

Answer 60

biorhythm and sleep

Question 61

changes in this reduce amt of deep sleep and time spent in REM sleep

Answer 61

sleep cycles

Question 62

can adversely affect cog, emotional, and physical functioning as well as quality of life

Answer 62

sleep deprivation and fragmented sleep

Question 63

Disturbed sleep in the presence of adequate opportunities and circumstances this is a DIAGNOSIS Difficulty falling asleep >1 month AND impairment in daytime functioning r/t poor sleep Primary vs. comorbid

Answer 63

insomnia

Question 64

Insomnia --> Medications and substance - Causes

Answer 64

drugs and ETOH (10-15% of insomnia)

Question 65

Sleep teachings

Answer 65

maximize comfort bedroom is for sleep avoid or limit naps <2 H exercise (not b4 bedtime) and outdoor time bedtime routine limit tobacco, caffeine, and ETOH -- in evening manage GERD avoid screen time just b4 bed if cant fall asleep -- go to another room until tired

Question 66

Use of sleep medications (box 17.10)

Answer 66

1. norm changes in sleep pattern with age 2. importance of appropriate assessment of sleep problems b4 any meds are used 3. sleep hygiene, stimulus control, sleep restrictions and relaxation techniques 4. avoid otc meds that contain benadryl. s/s = confusion, blurred vision, constipation, and falls 5. AE of sleep med, also OTC meds = problems with daily function, changes in mental status, possible motor vehicle accident, increase in daytime drowsy, and increase risk of falls with only minimal improvement of sleep 6. avoid benzos (flurazepam, triazolam, temazepam) for sleep due to long acting sedative effects 7. if sleeping meds are prescribed, benzos receptor agonists (zolpidem, eszopiclone, zaleplon) or ramelteon are preferred; given at lowest possible dose for short term use only (2-3 weeks, never longer than 90 days) meds for sleep should be taken immediately before bedtime 8. avoid use of alc, narcotic pain relieving meds, and antianxiety meds if taking sleep meds 9. review all meds, include OTC, with HC provider for interactions with sleep meds 10. using caution the day after taking sleep meds, particularly w driving and activities that require full alertness; accidents are common.

Question 67

older adults should avoid sleep aids, in general especially...

Answer 67

benzodiazepines

Question 68

OTC meds =

Answer 68

diphenhydramine (Benadryl)

Question 69

the preferred sleep RX are?

Answer 69

bensodiazepine receptor agonist (zolpidem) or melatonin receptor agonist (ramelteon) lowest dose (start 1/2 dose) short term zolpidem -- high ED visits for adverse drug reactions ALWAYS REMEMBER SAFETY

Question 70

periods of no breathing while sleeping

Answer 70

sleep apnea assess with Epworth sleepiness scale

Question 71

what are s/s of sleep apnea?

Answer 71

excessive daytime sleepiness snorting, gasping, choking headache, irritability symptoms are often blamed on age

Question 72

70% of men; 56% of women >65 y/o decline in tone of upper airway muscles linked to heart failure, cardiac dysrhythmias, stroke, T2DM, OP and death limit/stop ETOH and sedatives, weight loss, smoking, CPAP

Answer 72

Obstructive sleep apnea

Question 73

what are the obstructive sleep apnea risk factors?

Answer 73

increased age increased neck circumference (not a sign in older adults) male gender anatomical abnormal of the upper airway family history excess weight use of alc, sedatives, or tranquilizers smoking HTN

Question 74

Physical activity guidelines:

Answer 74

2.5 hrs weekly of moderate aerobic muscle strengthening activities at least 2 days per week -- all major muscle groups teachings: mod intensity aerobic muscle strengthening stretching balance

Question 75

cont. movement involving large muscle groups that is sustained for a minimum of 10 M, should make your heart beat faster

Answer 75

mod intensity aerobic

Question 76

cont. movement involving large muscle groups that is sustained for a minimum of 10 M, should make your heart beat faster

Answer 76

mod intensity aerobic

Question 77

involve moving or lifting some type of resistance and work all major muscle groups

Answer 77

muscle strengthening

Question 78

therapeutic maneuver designed to elongate shortened soft tissue structures and increase flexibility

Answer 78

stretching

Question 79

improve the ability to maintain control of the body over the base of support to avoid falling

Answer 79

balance

Question 80

Know the NO's ...

Answer 80

Don’t exercise when: SBP > 200 mm Hg DBP > 100 mm Hg Resting HR > 120 bpm For 2 hrs after a big meal

Question 81

what is guidelines for exercise safety?

Answer 81

comfy loose fitting clothes warm up drink h2o b4, during, and after clothes that absorb sweat wear sunscreen if exercise outside

Question 82

what are the age related changes for feet?

Answer 82

skin becomes drier, less elastic, cooler subQ tissue on dorsum and sides of foot thins plantar fat pad shrinks and degenerates toenails become brittle, thicken, less resistant to fungal infections degenerative joint disease decreased ROM

Question 83

Thick, compacted skin often from prolonged pressure. Pad and protect area is BEST. Proper fitting shoes.

Answer 83

Corns/Calluses

Question 84

Bony deformities – great toe or fifth toe from chronic squeezing or hereditary. Custom shoes, surgery, or steroid injection.

Answer 84

Bunions

Question 85

Permanently flexed toe (clawlike). Custom shoes or surgery.

Answer 85

hammer toe

Question 86

- Yellow, brown, opaque, brittle and thick nails. Difficult to treat – costly & limited effectiveness.

Answer 86

onchomycosis

Question 87

what is the proper foot care?

Answer 87

If DM - Must have annual foot exam by healthcare provider Care of toenails Best cut after bath or soaking 20-30 min – softens nails Clip straight across Proper fitting footwear Orthotic shoes as needed

Question 88

¹∕₃ over 65 y/o fall each year 10% sustain serious injury

Answer 88

geriatric syndrome --> falls

Question 89

falls are a ____________ of a problem

Answer 89

symptom

Question 90

what are consequences of falls?

Answer 90

Hip fractures Traumatic brain injury Fallophobia --> Fear of falling causing limitations in function

Question 91

what are the fall risk assessment tools?

Answer 91

Hendrich II Fall Risk Model Morse Fall Scale

Question 92

what are the major risk factors for falls?

Answer 92

Orthostatic hypotension Cognitive impairment Impaired vision and hearing Medications Environmental factors Weakness and frailty

Question 93

what are fall prevention interventions?

Answer 93

Fall risk reduction programs Fall bundles: Arm bands, signs, education, risk assessment, footwear, assisted toileting Environmental modifications Assistive devices Safe client handling Wheelchairs Alarms/motion sensors

Question 94

device to limit movement to prevent harm

Answer 94

restraints

Question 95

consequences of restraints in older adults?

Answer 95

Do not effectively prevent falls, wandering, or removing medical equipment Probably exacerbate the problem Restrain-related death: Asphyxiation Pressure ulcers, agitation, cognitive decline, depression

Question 96

Side rails?

Answer 96

Not simply a part of the bed Type of restraint: If two full length or four half length up Research evidence does not show side rails reduce falls or injury Some evidence that they increase injuries! Centers for Medicare and Medicaid (CMS): Require documentation of need for side rails

Question 97

What is restraint free care?

Answer 97

the goal for care in older should not be used to manage behavior symp treat underlying prob practice with the evidence

Question 98

What is the proper documentation that is needed to be done with restraints?

Answer 98

violent pt = every 15 M cognitive pt = every 30 M - 1H