Exam One Blueprint Flashcards
Describe why clinical decisions making is complex in older adults
What is a chronic condition
conditions that do not resolve within three months and complete cures are rare
What are geriatric syndromes
collection of sx not specific to one disease
What is a very important role a nurse plays in caring for a person with a chronic condition?
providing patient with proper education
Patients with chronic conditions often are placed on several medications. what is important for the nurse to do with these
-perform medication reconciliation
managing chronic illnesses involves more than treating medical problems such as
pain management, client accepting dependence, diet changes, etc
What is the sandwich generation?
when ‘middle-aged’ person has parents and children to take care of
Before chronic conditions develop, what is an important regimen of healthcare
prevention such as lifestyle changes/interventions
Once chronic disease occurs, patient focus shifts to?
managing symptoms, avoiding complications, maintaining functional status
What are very important challenges we must remember for our patients living with chronic illness
-the right to die with dignity and comfort
-psychological adjusting is hard
-self-worth may become diminished
Do geriatric syndromes always have a diagnosis?
no
What does it mean that geriatric syndromes are multifactorial
-many things cause it to happen
Do geriatric syndromes have high prevalence of poor outcomes in the elderly?
yes
Normal changes of the heart during old age
-heart muscles thicken with age
-heart rate lowers and oxygenation lowers
Normal changes of the arteries with age
-stiffen with age
-heart has to beat harder to push blood through the arteries
Normal changes of the lungs
-maximum breathing capacity declines beginning at age 40
Normal changes of the brain
-axons and neurons are lostNorm
al normal changes of the kidneys with age
kidneys gradually become less effective at removing waste from blood
normal changes in bladder function
bladder capacity declines
normal changes toBody fat with older age
weight declines, fat is redistributed to deeper organs making them more vulnerable to heart disease
normal changes to muscles with old age
muscle mass declines 22 percent in women and 23 percent in men
Normal changes to bones with aging
bone mineral is lost, especially in women
What steps can be taken to reduce bone loss
weight bearing exercises, high calcium diet
Normal changes to sight with old age
-40’s= difficulty seeing close up
-50 and up = sensitivity to glare, hard to see in little light, more difficulty detecting moving objects
-70= decline in fine details
Normal changes to hearing in the older adult
-more difficult to hear higher frequencies in the older adult
-background noise makes it harder
-declines more rapidly in men
Normal changes to personality in the older adult
-stable throughout adult life (especially if healthy)
-risk for depression and social isolation
What is homeostenosis?
the inability of the body to restore homeostasis, even after minor environmental challenges (trauma or infection)
Is immobility a chronic condition or geriatric syndrome?
geriatric syndrome
Examples of ADL’s
toileting, bathing, dressing, feeding, incontinence
Examples of IADL’s
driving, telephone, shopping, laundry, handling finances, handling medications, housekeeping
What two things do IADL’s require to maintain functioning
-physical and cognitive performance
Do older adults lose the ability to perform ADL’s or IADL’s first
IADL’s
One of the hardest parts of aging for the older adult includes?
losing independency
Why do healthcare workers often cause dependency in the older adult?
-easier to perform their tasks than allow them time to do it (autonomy)
What are normal mobility changes found in the older adult?
decline in speed due to decreased stride length
Falls in the community dwelling are mostly due to?
environmental factors and risky behaviors
Environmental factors that may cause falls?
-poor lighting
-excessive equipment
-wet floors
-loose carpets
-poorly fitting shoes
-new surroundings
-pets around feet
Causes of fall in hospital / LTC facilities include?
-bathroom seeking
-gait
-balance disorder
-dizziness
If there is a new onset or increased number of falls in our patient, what should the nurse question could be wrong with them?
-new onset of infection
-new medication side effects (such as anti-cholinergic)
what type of anemia is most likely to cause a fall
-B12
What electrolyte imbalance is most likely to cause a fall?
hyponatremia (below 120)
Is hyper or hypoglycemia more likely to produce afall
hypoglycemia
What medications are most likely to cause falls in the older adult
-anxiolytics
-sedatives
-tranquilizers
-cardiac meds
-corticosteroids
-NSAIDs
-anticholinergic drugs (such as diphenhydramine)
-hypoglycemic agents
Normal time for Get Up and Go Test (TUG)
less or equal to 11 seconds
Implications if the client cannot complete TUG in less than 12 seconds
physical therapy
What gait is characterized by a flexed hand + circumduction of the foot? they also have more weakness distally leading to foot drop
hemiplegic gait
What gait is characterized by universal flexion of almost every joint and small steps/shuffling? they may also have small tremors of the hands and arms.
Parkinson’s gait
What gait is characterized by a wide stand with a wide staggering quality?
ataxic / cerebellar
People with ataxic gait are more likely to fall towards what side?
the side of their cerebral illness
What is titubation?
when a patient with a cerebellar/ataxic gait stands still and has swaying of the trunk
Is the Romberg test a good indication for cerebellar / ataxic gait?
no
What is a stomping gait?
when a patient cannot see , so they stomp on the ground to feel vibrations in their trunk that their foot is landed
Is stomping gait more evident in the daytime or nighttime?
nighttime because in the daytime patients can typically watch their own feet
What is the cerebral palsy/ diplegic gait?
arms flexed, adduction keeping their feet together, seem to walk on tiptoes (commonly seen in children)
What gait happens to people with myopathy?
waddling gait
-pelvis drops on both sides while walking, with the head leaning the opposite way to prevent falling
What is the neuropathic / steppage gait?
-when a patient has peripheral neuropathy and foot drop
-patient takes high steps so they do not trip on their foot and fall
trendelenburg vs waddling gait
trendelenburg occurs with myopathy on one side
-pelvis drops on opposite side of hip myopathy
What is the cautious gait?
-usually occurs after a fall
-wide stance, reduced arm swing, slightly stooped posture
Factors to consider when assessing the home for falls?
-rugs, clutter, foot wear, lights, hand rails/stairs, pets, how active they are, do they live alone, comorbidities, medications
do the active or inactive older adults have a higher risk for falls?
active
Physical consequences of falls?
-hip fracture (1/4 die < 6 most after multiple falls)
-pressure ulcer
-pneumonia
What is constipation
infrequent, incomplete, or painful evacuation of feces
How many days constitute constipation
no BM in 3 days
With normative BS, we should hear gurgling every
5-10 seconds
how long do we listen if we do not hear BS in any quadrant
5 minutes
What are some causes of constipation in older adults
-drinking less water
-medications
-eating less fiber
-disease
-inactivity
Why does overuse of laxatives lead to constipation?
dependency can form
why are older adults more likely to eat sweets than normal food
decline in taste buds make sweets taste better
What foods should we encourage the older adult to eat to prevent constipation>
fiber, prunes, coffee, bran, fiber one
How can diabetes cause constipation?
neuropathy can slow down gastric motility
What other diseases slow down gastric motility and may lead to constipation in the older adult?
Hypothyroidism, MS, Parkinson’s
Passive peristalsis can be increased by
-exercise such as walking and leg lifts
What medications are likely to cause constipation in the older adult?
anticholinergics and narcotics (pg 548)
How much fiber does an older adult need a day to help prevent constipation
35-50 g / day
How much water does an older adult need to help prevent constipation
at least 2 L / day (unless contraindicated)
What is the ‘colon cocktail’ recommended to some older adults
equal parts prune juice, apple sauce, and psyllium. they should take 1-2 tablespoons daily
Water’s role in preventing constipation
softens stool to make it easier to pass and prevent straining
What should be done first when treating patients with constipation
lifestyle modifications and medication review
What are examples of lifestyle modifications we can implement to prevent constipation in our patients
bowel retraining, regular toileting schedule, use of fiber
Are prokinetic agents such as bethanechol and metoclopromide recommended in the elderly?
no
Why should older adults not take metoclopramide
-potential for tardive dyskinesia and other EPS symptoms (which have to be treated with diphenhydramine)
Why are hyperosmolar agents such as polyethylene glycol recommended in the elderly ?
-effective and non addictive
What are the most physiologic treatment products for constipation?
bulk forming laxatives
Example of bulk forming laxative?
psyllium
Example of surfactant laxative (stool softener)
docusate sodium
What are examples of osmotic laxatives
magnesium hydroxide, polyethylene glycol, lactulose
What are examples of stimulant laxatives
bisacodyl, Senna
If on a narcotic, what can be an adverse effect of this medication
opioid induced constipation
If a patient is on a narcotic, what should be prescribed with them to prevent constipation
stimulant laxative
Polyethylene glycol use puts our patient at risk for?
-dehydration (monitor I I’s and O’s)
Chronic laxative use can lead to
fluid and electrolyte imbalances
What two reasons make zofran a risk for causing constipation
-anticholinergic effects
-nauseas people typically aren’t drinking water
Why is assessing patient transportation , food insecurity, and loneliness important?
may lead to poor nutrition
If the measures of the ‘colon cocktail’ do not work, we should inform older adults to
take a stool softener
Why do older adults often decrease fluid intake in the evening
decreased mobility, prescribed diuretics, and urinary incontinence
Fluid restrictions in the older adult can lead to dehydration and electrolyte imbalances such as
sodium and potassium
many older adults in the community are at risk for poor health due to
poor health literacy
Is urinary incontinence considered a normal part of aging?
No
Why is assessing for urinary incontinence in the older adult important?
-many are too embarrassed to admit
-major reason for LTC placement
-affects 1/3 of community - dwelling older adults
What is urge incontinence?
-abrupt, strong urge to void with moderate to large amounts of leakage
Causes of urge incontinence?
-UTI
-bladder spasticity
-caffeine
-CNS lesions (stroke/dementia)
What is stress incontinence
instantaneous leakage during increased intraabdominal pressure
Causes of stress incontinence
-pelvic muscle or ligament laxity (looseness of muscle)
-trauma from prostate surgery
-childbearing
-changes with menopause
Stress incontinence may be brought on when a patient
sneezes, coughs, laughs, has obesity, is pregnancy
What is overflow incontinence?
restriction of flow of urine leads to distended bladder
Causes of overflow incontinence?
-atonic (lack of muscle tone) bladder
-Medications
-injury (TBI)
-impaired contractility
What prostate condition in men regularly leads to overflow incontinence?
BPH (bladder outlet obstruction)
What types of medications lead to overflow incontinence
anticholinergics, anesthetics
what conditions can lead to impaired contractility and overflow incontinence
-b12 deficiency, diabetes, alcoholism
-stroke, MS, parkinsons
this occurs due to improper innervation of the bladder
What is functional incontinence
inability or unwillingness to toilet
Reasons that may cause functional incontinence
impaired cognition, environment, impaired mobility, psychological
Incontinence and how it affects patient safety
causes increased risk of falls
Incontinence and how it affects quality of life
may cause increased depression and social isolation (out of fear of not being able to get to a bathroom)
When is it appropriate to catheterize a patient with incontinence
- overflow of bladder (not emptying)
- significant sacral wounds
- if on hospice
Why should medication review be completed on those with incontinence
some medications cause urinary retention while others may cause frequency
Why should we evaluate a client’s pelvic floor if they have incontinence?
weak pelvic floor muscles may lead to stress incontinence
What is pelvic floor therapy?
-exercises to strengthen pelvic floor muscles and open urethra
For a better understanding of their incontinence, what may patients be instructed to do to generate solutions
-3 day voiding diary
Why is postvoid residual volume used to determine incontinence
-uses catheter or ultrasound to confirm urine left in the bladder after attempting to pee
What labs may be evaluated to generate solutions for incontinence
-UA, BUN, Cr, WBC
Post void residual will be low in what type of incontinence
-urge incontinence
Post void residual will be high in what type of incontinence?
-overflow incontinence
Treatment for urge incontinent includes
-initial therapy Kegels / PFT
-treat UTI
-Medications
-scheduled toileting for cognitive defects
Atrophic vaginitis, a common cause of urge incontinence, is treated with
estrogen cream
Our main concern for our patients on topical estrogen cream is
-applying it properly (2-3 days a week) to prevent systemic effects
Other medications to treat urge incontinence include
-tricyclic agents (imipramine)
-tolterodine tartrate, Darifenacin, Solifenacin, or Oxybutynin
Imipramine, a tricyclic agent used to treat urge incontinence, puts the patient at risk for
postural hypotension
How does oxybutynin work?
relaxes bladder muscles
Oxybutynin puts our patient at risk for
-anticholinergic affects
-slow reaction times
-orthostatic hypotension
Treatment for stress incontinence includes
-evaluating medications that may aggravate
-Kegels/PFT
-treat atrophic vaginitis
-weight loss
-insertion of pessary
-toileting and fluid regimen
-surgery
What is a pessary?
-a device inserted into the vagina to support your pelvic organs
Why is surgery sometimes needed to treat stress incontinence
bladder tips back into pelvis after hysterectomy
Treatment for overflow incontinence
-medication review
-bladder retraining
-improve glucose readings (diabetics)
-reduce ethanol / alcohol intake
How to treat functional incontinence
-remove barriers to BR use
-use pictures on BR door
-improve mobility with PT / OT
Tamsulosin, used to treat BPH and overflow, puts the patient at risk for?
-hypotension and falls
How does tamsulosin work?
by dilating the urethra
How do Kegel/ pelvic floor exercises help reduce incontinence
-strengthen the pelvic floor muscles
How should we educate our patients to perform kegal exercises?
-tighten pelvic muscles for a slow count of 10 and then relax for a slow count of ten
-perform 15 reps while laying, sitting, and standing
-finish with 10 rapid contractions
-repeat 10 times a day
what is the most common reason older adults become delirious and why?
-surgery because they do not process anesthesia as fast (most commonly cardiac)
Other causes for delirium include?
-infection (UTI)
-hypoxia (not enough oxygen getting to brain)
-hypoperfusion (less oxygenation)
-trauma
-pain
-hypo/hypernatremia
-dehydration
-restraints
-medications
-constipation
How does cholinergic deficiency cause delirium?
-decreased acetylcholine
How does dopaminergic excess cause delirium
-increased amounts of dopamine
What medications commonly cause delirium?
-anticholinergics
-benzodiazepines
-narcotics (specifically meperidine or codeine)
Delirium can be treated by resolving the cause of it. Give examples:
-treating hypovolemia with fluids
-treating UTI / infections
-getting patients out of bed during the day so they sleep at night
Symptoms of delirium
-confusion
-inattention
-restlessness
-hallucinations
-change in level of consciousness
-incoherence
-anxiety
-illusions
-delusions
-fear
-excitement
How do we assess for delirium?
CAM (confusion assessment method)
How to interpret results from the CAM
to be positive, the patient must display signs of
-section 1 and 2 + 3 OR 4
section 1: acute onset and fluctuations
section 2: inattention
section 3: disorganized thinking
section 4: altered LOC
Why is it important to have family at the bedside and maintain consistent caregivers for patients experiencing delirium?
-provides therapeutic environment
-makes it easier to re-orient them
What may be administered to our delirious patients to promote adequate sleep?
low dose trazodone
What is polypharmacy?
when patients are on more meds than are clinically necessary
Polypharmacy includes both
prescription and OTC drugs
80% of older adults age 65-79 are on ____ medications/day
14
80% of older adults greater than 80 are on ___ medications/day
18
What are cues nurses should recognize that our patient is apart of polypharmacy
- multiple forms of the same medicine
- medication no longer needed clinically
- more drugs than the patient can physically take (high pill burden)
What categories of medications are often stacked and lead to polypharmacy
-BP and diabetic meds
The risk of medication errors increases when
patients are transferred in care (ex: hospital –> LTC )
When should medication reconciliations be completed
- each admission and discharge of acute care
- each provider visit
- by pharmacist, etc
Why are medication reconciliation sometimes inaccurate?
-personal patient lists aren’t updated/ patients unable to communicate correctly
-illegibility of MAR’s on transfer
-same pharmacies aren’t used
How many chronic conditions increases patient risk for MRP and ADE
6
How many doses of drugs/ day puts patient at risk for MRP and ADE
12
How many medications put patient at risk for MRPs and ADEs
9
Having a low body weight or BMI increases or decrease the risk for an ADE?
increases
Having a previous adverse drug reaction means?
the patient is more at risk of having another
What age is a risk factor for MRPs and ADEs
85 or older
Our patient is at risk for MRPs and ADEs if their creatinine clearance is an estimated
< 50 mL/min
Most common adverse effects of drug-drug interactions?
-confusion
-cognitive impairment
-arterial hypotension
-acute renal failure
What drugs have a high potential for severe ADE’s?
-amitriptyline
-chlorpropramide
-Digoxin > 0.125 mg/ day
-Disopyramide
-GI antispasmodics
-meperidine
-methyldopa
-pentazocine
-ticlopidine
What drugs have a high potential for less severe ADE’s
-antihistamines
-dipyridamole
-ergot mesylates
-indomethacin
-meperidine, oral
-muscle relaxants
How is absorption of medications affected in the older adult?
-gastric pH increases, GI motility decreases, and gastric blood flow decreases
How is drug distribution affected in the older adult?
-small amounts of total body water and increased fat
-decreased albumin level
Lipid soluble drugs and the older adult
-more body fat allows for the medication to stay in the body longer = toxicity
Highly protein bound drugs and the older adult
-less protein = less inactivation of the drug
-may lead to toxicity in the older adult
Decreased GFR and Creatinine clearance in the older adult increases their risk of ?
-toxicity due to slir ow excretion of drugs
Drugs with a high first-past metabolism and their effect on the elderly
-decreased hepatic blood flow = decreased ability to inactivate drug –> increased bioavailability and risk for toxicity
How can we ensure safe use of drug therapy in the older adult
-performing medication reconciliations at the correct time and with accuracy
-ensure they are using mechanisms to properly take their medications
-monitor creatinine clearance, GFR, and drug levels if needed
Popular anticholinergic drugs seen on the Beer’s list that may cause ADE’s in the elderly?
First generation antihistlamines
-diphenhydramine
-promethazine
-dimenhydrinate
Antiparkinsonian Agents
-benztropine
Antispasmodics
-atropine
-scopolamine
TCA
-amitriptyline
