Exam 2: Gero Lecture 5 Flashcards
dry cracked itchy skin. inadequate fluid intake worsens. use super-fatted soaps and cleansers
xerosis
itchy skin. a symptom not a diagnosis. may be r/t med side effects or secondary to disease. a threat to skin integrity.
pruritis
thin fragile skin – extravasation of blood into surrounding tissue. wear long sleeves and protect from trauma.
purpura
precancerous skin lesion. from sun exposure. derm visits every 6-12 months to monitor and treat
actinic keratosis
waxy, raised, “stuck on” appearance, benign lesion. almost ALL older adults over 65 y/o
seborrheic keratosis
painful vesicular rash over a dermatome, get vaccine at age 60
herpes zoster
yeast infection, often in skin folds. keep skin clean and dry
candidiasis
where are the highest incidences reported for pressure injuries?
hospitalized or institutionalized older adults and vulnerable adults undergoing orthopedic procedures
can significantly impair recovery/rehab and impact QOL. increased risk for mortality, high prevalence of health care litigation.
pressure injury
CMS now considers pressure ulcers a __________________ adverse event and do NOT reimburse treatment for pressure ulcers acquired during admission.
preventable
key factor in maintaining health =
important factor in delaying onset and managing chronic illness =
adequate nutrition
adequate diet
what does proper nutrition include?
carbohydrates – 45-65%
fat – 20-35%
protein – 10-35%
vitamins and minerals – 5 servings of fruit and veggies
what is overweight BMI?
25-29.9
what is obese BMI?
30-39.9
what is morbid obese BMI?
40+
1/3 of 65+ are obese, the majority are…
women
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.
malnutrition
increased risk of what in malnutrition?
infection
pressure ulcers
anemia
hip fractures
hypotension
impaired cognition
increased morbidity and mortality
difficulty swallowing, about 20% of those over 50 y/o, and up to 60% of LTC residents.
dysphagia
dysphagia risk factors?
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
dysphagia symptoms?
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
dysphagia symptoms?
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
dysphagia prevention of aspiration
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
PEG tubes in advanced dementia myths?
prevent death from inadequate intake
reduce aspiration pneumonia
improve nutritional status
provide comfort at end of life
PEG tubes in advanced dementia FACTS?
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
adequate fluid consumption and maintenance of fluid balance essential to health
hydration
what are risk factors for changes in fluid balance?
Physiological changes in body water content
Impaired thirst sensation
Medications
Functional impairments
Chronic illness
Emotional illness
High environmental temperatures
what are reasons why dehydration risk increases with age?
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
What are the dehydration categories?
can drink
can’t drink
won’t drink
end of life
can drink =
able to drink
may not know whats adequate
possible cog impair
encourage and make fluids accessible
can’t drink =
physical incapable to ingest or accessing fluids
dysphagia prevention
swallow evaluation
safe drinking techniques
won’t drink =
highest risk for dehydration
able to drink but refuses
offer frequently
prevent incontinence
end of life =
terminally ill
could be any of the previous 3
refer to advanced directives with regard to hydration wishes
what are signs of dehydration?
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)
How is dehydration generally confirmed?
lab testing
What are hydration interventions?
at least 1500 mL/day (2-3 L)
water is best
offer often
make readily available
encourage with meds
provide preferred fluids
verbal reminders
what is urinary incontinence?
urge, stress, functional
What are urinary incontinence interventions?
scheduled and prompted voiding
pelvic floor muscle exercises (kegals)
thorough assessment of continence
lifestyle modifications
meds
urinary cath –> last resort
What meds can worsen UIs?
meds with anticholinergic properties and diuretics
What is the most common cause of sepsis in older adults?
UTIs
often asymptomatic, cog impaired may not report symptoms, and normal for older adults to be asymptomatic, uncomplicated bacteria in urine.
UTI
often asymptomatic, cog impaired may not report symptoms, and normal for older adults to be asymptomatic, uncomplicated bacteria in urine.
UTI
what are atypical symptoms with UTIs?
mental status changes
decreased appetite
incontinence
reduction in BM freq or difficulty in forming or passing stools. 40% older adults experience (more common in women)
constipation
what are complications of constipation?
impaction
obstruction
cog dysfunction
delirium
falls
increased morbidity and mortality
increased risk for bowel cancer
Age related bowel changes: small intestine
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.
What are constipation interventions?
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
bulk-forming (fiber)
psyllium (metamucil)
emollients
docusate sodium
osmotic
polyethylene glycol (PEG), milk of magnesia, lactulose
stimulant
bisacodyl, senna
enemas:
last resort
don’t use on regular basis
may alter fluid and electrolyte status
sodium phosphate enemas contraindicated in older
bulk forming (psyllium, methylcellulose)
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
emollients and lubes (docusate sodium and mineral oil)
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
osmotic laxatives (milk of mag, lactulose sorbitol, polyethylene glycol (PEG, miralax)
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
stimulant laxatives (senna, bisacodyl)
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
complication of constipation, common in incapacitated and those in institutions (increased incidence with narcotics)
fecal impaction
what are CM and complications of fecal impaction?
malaise
urinary retention
increased temp
incontinence
cog decline
hemorrhoids
intestinal obstruction
what is the nursing management for fecal impactions?
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
What are the sleep stages?
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
Sleep –> aging associated with:
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
age related changes in the body perception of light-dark cycles and circadian sleep wake rhythm
biorhythm and sleep
changes in this reduce amt of deep sleep and time spent in REM sleep
sleep cycles
can adversely affect cog, emotional, and physical functioning as well as quality of life
sleep deprivation and fragmented sleep
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
insomnia
Insomnia –> Medications and substance - Causes
drugs and ETOH (10-15% of insomnia)
Sleep teachings
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
Use of sleep medications (box 17.10)
- norm changes in sleep pattern with age
- importance of appropriate assessment of sleep problems b4 any meds are used
- sleep hygiene, stimulus control, sleep restrictions and relaxation techniques
- avoid otc meds that contain benadryl. s/s = confusion, blurred vision, constipation, and falls
- 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
- avoid benzos (flurazepam, triazolam, temazepam) for sleep due to long acting sedative effects
- 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
- avoid use of alc, narcotic pain relieving meds, and antianxiety meds if taking sleep meds
- review all meds, include OTC, with HC provider for interactions with sleep meds
- using caution the day after taking sleep meds, particularly w driving and activities that require full alertness; accidents are common.
older adults should avoid sleep aids, in general especially…
benzodiazepines
OTC meds =
diphenhydramine (Benadryl)
the preferred sleep RX are?
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
periods of no breathing while sleeping
sleep apnea
assess with Epworth sleepiness scale
what are s/s of sleep apnea?
excessive daytime sleepiness
snorting, gasping, choking
headache, irritability
symptoms are often blamed on age
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
Obstructive sleep apnea
what are the obstructive sleep apnea risk factors?
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
Physical activity guidelines:
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
cont. movement involving large muscle groups that is sustained for a minimum of 10 M, should make your heart beat faster
mod intensity aerobic
cont. movement involving large muscle groups that is sustained for a minimum of 10 M, should make your heart beat faster
mod intensity aerobic
involve moving or lifting some type of resistance and work all major muscle groups
muscle strengthening
therapeutic maneuver designed to elongate shortened soft tissue structures and increase flexibility
stretching
improve the ability to maintain control of the body over the base of support to avoid falling
balance
Know the NO’s …
Don’t exercise when:
SBP > 200 mm Hg
DBP > 100 mm Hg
Resting HR > 120 bpm
For 2 hrs after a big meal
what is guidelines for exercise safety?
comfy loose fitting clothes
warm up
drink h2o b4, during, and after
clothes that absorb sweat
wear sunscreen if exercise outside
what are the age related changes for feet?
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
Thick, compacted skin often from prolonged pressure. Pad and protect area is BEST. Proper fitting shoes.
Corns/Calluses
Bony deformities – great toe or fifth toe from chronic squeezing or hereditary. Custom shoes, surgery, or steroid injection.
Bunions
Permanently flexed toe (clawlike). Custom shoes or surgery.
hammer toe
- Yellow, brown, opaque, brittle and thick nails. Difficult to treat – costly & limited effectiveness.
onchomycosis
what is the proper foot care?
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
¹∕₃ over 65 y/o fall each year
10% sustain serious injury
geriatric syndrome –> falls
falls are a ____________ of a problem
symptom
what are consequences of falls?
Hip fractures
Traumatic brain injury
Fallophobia –> Fear of falling causing limitations in function
what are the fall risk assessment tools?
Hendrich II Fall Risk Model
Morse Fall Scale
what are the major risk factors for falls?
Orthostatic hypotension
Cognitive impairment
Impaired vision and hearing
Medications
Environmental factors
Weakness and frailty
what are fall prevention interventions?
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
device to limit movement to prevent harm
restraints
consequences of restraints in older adults?
Do not effectively prevent falls, wandering, or removing medical equipment
Probably exacerbate the problem
Restrain-related death: Asphyxiation
Pressure ulcers, agitation, cognitive decline, depression
Side rails?
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
What is restraint free care?
the goal for care in older
should not be used to manage behavior symp
treat underlying prob
practice with the evidence
What is the proper documentation that is needed to be done with restraints?
violent pt = every 15 M
cognitive pt = every 30 M - 1H
