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Older Adult Final Exam Review Lecture and Text notes Sessions 6-12.docx

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NURS 1700U
A.De La Rocha

Older Adult Final Exam Review - the theoretical perspectives on aging ("Try not to memorize, but to imagine what this would look like in patients you're caring for") - stochastic theories and be able to identify what each of these theories would look like - study the physiological changes (enlarged prostate gland, reduced sperm, what does loss of skin integrity mean), - FANCAPES and other tools- know how to use them and what would be most the appropriate situation to use them in, - understand how to promote fluid and fiber, - understand the constipation decision tree (?), - types of incontinence, - pain and comfort (what causes/are precursors to these illnesses, what are nursing interventions, what health teaching can you do? Recognize S&S) - steps of geropharmacology - **loss and grief - palliative care - when someone close to you is dying booklet - health challenges (presbyopia, etc.) - 3 Ds of cognitive impairment Session 6:  Health challenges Older Adult and psychophysical needs ·Aging can be viewed in terms of chronological age, biological age, psychological age, and social age. ·Sociological theories of aging attempt to explain and predict changes in roles and relationships in middle and later life, with an emphasis on adjustment. ·Age-stratification theory goes beyond the individual to the age structure of society. ·Social exchange theory challenges both disengagement theory and activity theory; it is based on the consideration of the cost-benefit model of social participation. ·Modernization theory focuses on the social changes that have resulted in the devaluing of both the contributions of older people and the older people themselves. ·Symbolic interaction theories propose that the aging process that a person experiences is a result of interactions between the environment, the individual, and the meaning the person attributes to his or her activities. ·Psychological theories presuppose that aging is one of many developmental processes experienced between birth and death; life is a dynamic process. Sleep ·An older adult requires 7-8 hours of sleep a night. ·Although complaints of sleep difficulty are common, because aging is associated with changes in the amount of sleep, sleep quality, and specific sleep disorders such as insomnia, sleep apnea, restless leg syndrome, and circadian rhythm disturbances, they should be thoroughly investigated and not attributed to age. ·Restless leg syndrome is the primary reason patients seek treatment. Restless leg syndrome (RLS) is a sensorimotor neurological disorder characterized by uncontrollable need to move the legs, often accompanied with discomfort. Other symptoms could include paresthesias characterized by creeping or crawling sensations, tingling, cramping, burning sensations, and pain. ·REM Sleep Behaviour Disorder is a sleep disorder characterized by loss of normal voluntary muscle atonia during REM sleep; involving punching and kicking and with a mean age of 60 years. An estimated 0.5% of the population are affected. May be primary or secondary to neurodegenerative diseases like Parkinson’s disease and Alzheimers. May be an early sign of Parkinson’s disease. Caffeine and medications may contribute. Assessments should include the environment (routines, temperature), and information about hobbies, life satisfaction, health perception, and depression screening. ·People with dementia benefit from behavioural techniques (sleep hygiene education, daily walking, increased light exposure). ·A thorough assessment includes exploring how well the person sleeps at home, how many times the person awakes at night, what time the person retires to bed, and what rituals occur at bedtime. · Medications may be used in combination with behavioural interventions, but must be chosen carefully, started at the lowest possible dosage, and monitored closely to avoid untoward effects in older adults. · Regular physical activity throughout life is likely to enhance health and functional status as people age, while also decreasing the number of chronic illnesses and mobility and functional limitations often assumed to be part of growing old. · Suggestions for exercise programs are based on the individual person’s preference and medical history, and should include endurance, strength, balance, and flexibility components. Box 10­3  Factors Contributing to Sleep Problems in Older Adults • Age­related changes in sleep architecture • Comorbidities (cardiovascular disease, diabetes, pulmonary disease, musculoskeletal disorders),  CNS disorders (Parkinson's disease, seizure disorder, dementia), GI disorders (hiatal hernia,  GERD, PUD), urinary disorders (incontinence, BPH) • Depression, anxiety, delirium, psychosis • Medications • Life stressors • Limited exposure to sunlight • Environmental noises, institutional routines • Poor sleep hygiene • Lack of exercise • Excessive napping • Caregiving for a dependent person • Sleep apnea • Restless leg syndrome • Periodic leg movement • Rapid eye movement behaviour disorder • Alcohol • Smoking Falls · Falls account for 71% of major injury hospitalizations, with 57% of falls occurring at home. 87% of seniors who fell received a severe injury to the head or spine · Falls are the 6 leading cause of death among older adults · Over 95% of hip fractures among older adults are caused by falls · Extrinsic factors: Carpets, footwear, steps, ice. uneven surfaces, clutter, pets, unstable furniture, exposed electrical cords, scatter rugs, spills, lack of assistive devices to promote functionality · Instrinsic factors: Sensory changes (vision, hearing), cognitive abilities, gait disturbances, cardiac issues, postural/orthostatic hypotension, disease, illness, meds · Tai chi: improves flexibility, lower extremity strength, postural stability, and balance; 55% decreased falls risk after 6 months 3/week · Fear of falling: Loss of confidence that leads to reduced physical activity, increased dependency and social withdrawal; stiffened gait pattern used to compensate puts them more at risk · · Screening: Morse Fall Scale; The Hendrich II Fall Risk Model; flags for at risk patients, Session 7:  Coping with chronic health challenges: pain and comfort and  geropharmacology - Acute illness occurs suddenly and often without warning - Includes: stroke, MI, hip fracture, infection - Chronic illness is managed rather than cured; always present but not always visible - Barriers to pain management in older adults: pain in cognitively impaired elders, pain at end of life - PQRSTU method assessment - What to look for in cognitively-impaired individuals: facial expression (frowning, grimacing, eyes tight shut, rapid blinking, fright), vocalization, body movements, change in behaviour (loss of appetite, social withdrawal, change in sleep/rest, fatigue, overall functional decline), change in mental status (crying, increased confusion, irritability, depression), physical manifestations (acute pain only) (tachycardia, hyperventilation, hypertension, diaphoretic, flushing - If unsure, treat the behaviour as an expression of pain and evaluate your intervention for effectiveness. - Osteoporosis: Porous bone; reduced bone mineral density, altered amount and variety of proteins in the bone. BMD (bone mineral density) of 2.5 standard deviations below peak bone mass (30 year old average) measured via X-ray. Primary osteoporosis is thought to be part of normal aging for women. Secondary osteoporosis is porous bones caused by another disease state. Affects ¼ women and 1/8 men over 50. o S&S: Diagnosed through DEXA scan, presumed with fractures, loss of 3 in or more in height, kyphosis o Weight-bearing physical activity and exercise helps maintain bone mass, as well as calcium and vitamin D intake. o Risk factors: females, white race, Northern European ancestry, advanced age, family history o Modifiable risk factors: Low body weight (underweight), low calcium intake, estrogen deficiency, low testosterone, inadequate exercise/activity, steroid use/anticonvulsants, excessive coffee/alcohol intake, present smoking • Osteoarthritis: • Rheumatoid arthritis: Rheumatoid arthritis produces swelling, inflammation, intense pain, and joint distortion. • Gout: A common form of inflammatory arthritis in older adults; appears to result from accumulation of uric acid crystals in a joint- produced when purines in food break down. An acute and chronic condition, goal of treatment is to minimize future attack. o Upon onset, the joint is in extreme pain usually in the middle of the night during sleep. the joint is bright purple/red, hot, and painful to touch. Involves the proximal joint of the great toe, or ankle, wrist, or elbow. o Risk factors for future attacks include high blood pressure, diet high in purines, and meds such as aspirin, niacin, and thiazide diuretics. o Fluid intake is important to flush uric acid through the kidneys (2L/day) o Nurse should notify physician of any renal dysfunction/change • Assessment When assessing the musculoskeletal system, the nurse examines the joints and muscles for tenderness, swelling, warmth, and redness. In OA, crepitus is felt or heard in the affected joints. The hands are examined for the presence or absence of osteophytes. If they appear in the distal joints as deformities of the fingers, they are called Heberden's nodes; they are called Bouchard's nodes in the proximal joints. Both passive and active range of motion is evaluated. How far can the person reach and bend all joints without assistance, and what are the reach, flexion, and extension with assistance? The testing of range of motion must go only to the point of discomfort and never to that of inducing pain. The functional ability of the arms is tested by asking the person to touch the back of the head and mid-back with both hands. A pain assessment is always included. Risk Factors for Heart Disease • Age (55 years for men; 65 years for women) • Family history of premature CHD (55 years for men, 65 years for women) • Microalbuminuria or estimated GFR, 60 mL/min * • Hypertension • Cigarette smoking • Central obesity (BMI ≥30) * • Physical inactivity • Dyslipidemia * * • Diabetes, IGT, or IFG • CHD, Coronary heart disease; GFR, glomerular filtration rate; BMI, body mass index; IGT, impaired glucose tolerance; IFG, impaired fasting glucose. • Components of metabolic syndrome. 10-5 Modifiable Factors That Increase the Risk for Essential Hypertension • Cigarette smoking or tobacco use • Excessive alcohol intake • Sedentary lifestyle • Inadequate stress/anger management • High-sodium diet • High-fat diet Signs of Potential Exacerbation of Illness in an Older Adult with Coronary Heart Disease • Light-headedness or dizziness • Disturbances in gait and balance • Loss of appetite or unexplained loss of weight • Inability to concentrate or shortened attention span • Changes in personality • Changes in grooming habits • Unusual patterns in urination or defecation • Vague discomfort, frequent bouts of anxiety • Excessive fatigue, vague pain • Withdrawal from usual sources of pleasure Thrombolytic therapy—post myocardial infarct—must be administered within the first two hours can occasionally abort myocardial infarction and dramatically reduce the mortality rate. All eligible patients should receive intravenous alteplase as soon as possible after hospital arrival, with a target door-to-needle time of less than 60 minutes. Atypical Symptoms of Heart Failure in Older Adults NON-CEREBRAL • Chronic cough • Insomnia • Weight loss • Nocturia • Syncope CEREBRAL • Delirium • Falls • Anorexia • Decreased functional capacity Topics of Education Related to Living with Heart Failure 1. Activities: pacing and tolerance 2. Exercise: strategizing adherence to prescribed program 3. Medications: timing, side effects, evaluation of effectiveness, obstacles to adherence 4. Disease self-management: signs and symptoms of exacerbation, intake, output and weight, when to call for help or questions, interpreting laboratory values, diet Comparison of Arterial and Venous Insufficiency of the Lower Extremities Characteristics Arterial Venous Pain Sudden onset with acute; Deep muscle pain with gradual onset with chronic acute deep vein thrombosis Exceedingly painful Relieved by elevation Claudication relieved by rest Rest pain relieved by dependency (with total occlusion, no position will give complete relief) Pulses Absent or weak Normal (unless arterial disease is also present) Associated changes in Thin, shiny, dry skin Firm (“brawny”) edema Thickened toenails Reddish brown leg and foot discoloration with postphlebitic syndrome Absence of hair growth Evidence of healed ulcers Temperature variations (cooler Dilated and tortuous if no cellulitis is present) superficial veins Elevational pallor Swollen limb Dependent rubor Increased warmth and erythema with acute deep vein thrombosis Atrophy or no change in limb size Ulcer location Between toes or at tips of toes Primarily the medial malleolus and the lower leg Over phalangeal heads On heels Over lateral malleolus or pretibial area over metatarsal heads, on side or sole of foot Ulcer characteristics Well-defined edges Uneven edges Black or necrotic tissue Ruddy granulation tissue Deep, pale base Superficial Non-bleeding Bleeding Guidelines for Persons Living with Venous Insufficiency GIVE LEGS A REST Elevate the feet above heart level while sleeping and several times a day. If necessary, elevate the foot of the bed or mattress. CHANGE POSITIONS FREQUENTLY Avoid activities that require standing or sitting with feet on the ground for long periods. GIVE LEGS SUPPORT Wear professionally made compression stockings that apply even pressure from ankles to knees. Learn how to put them on correctly. Have at least two pairs of the compression hose available so they can be changed daily. After laundering, hang up to dry. DO NOT PUT IN DRYER. Buy new compression hose every 6 months; after that period, the elastic is stretched. Put hose on early in the morning; wear all day; remove at bedtime. Avoid elastic bandages (e.g., Ace). They are difficult to wrap and exert uneven pressure. If a compression pump has been prescribed, follow the instructions. Symptoms of TIA (Transient ischemic attack) or Stroke. • Sudden weakness or numbness on one side of the body (face, arm, or leg) • Dimness or loss of vision in one eye • Slurred speech, loss of speech, difficulty comprehending speech • Dizziness, difficulty walking, loss of coordination, loss of balance, a fall • Sudden severe headache • Difficulty swallowing • Sudden confusion • Nausea and vomiting Risk Factors for Stroke/TIA • Heart disease (and risk factors for) • Hypertension • Arrhythmia • Hypercholesterolemia • Diabetes • Smoking • Coagulopathies • Brain tumor • Family history Risk Factors for Diabetes Mellitus • Ethnicity • Increasing age • Blood pressure ≥140/90 mm Hg • First-degree relative (parent, sibling, child) with diabetes mellitus (DM) • History of impaired glucose tolerance or impaired fasting plasma glucose • Obesity: ≥120% of desirable weight or body mass index (BMI) ≥30 kg/m 2 • Previous gestational DM or having had a child with a birth weight of ≥9 pounds • Undesirable lipid levels: high-density lipoproteins (HDLs) ≤35 mg/dL or triglycerides ≥250 mg/dL Signs and Symptoms Suggestive of Diabetes in the Elderly 1. General symptoms such as polyphagia, polyuria, polydipsia, and occasional weight loss 2. Recurrent infections, particularly of bacterial or fungal origin, that involve the skin, intertriginous areas, or urinary tract and sores or wounds that tend to heal slowly 3. Neurological dysfunction, including paresthesia, dysesthesia, or hyperesthesia; muscle weakness and pain (amyotrophy); cranial nerve palsies; and autonomic dysfunction of the gastrointestinal tract (diarrhea); cardiovascular system (orthostatic hypotension, arrhythmias); reproductive system (impotence); and bladder (atony, overflow incontinence) 4. Arterial disease (macroangiopathy) involving the cardiovascular, cerebrovascular, or peripheral vasculature structures 5. Small-vessel disease (microangiopathy) involving the kidneys (proteinuria, glomerulopathy, uremia) and eyes (macular disease, exudates, hemorrhages) 6. Lesions of the skin, such as Dupuytren's contractures, facial rubeosis, and diabetic dermopathy 7. Endocrine-metabolic complications, including hyperlipidemia, obesity, and a history of thyroid or adrenal insufficiency (Schmidt's syndrome) 8. A family history of type 1 or type 2 diabetes and a poor obstetrical history (miscarriages, stillbirths, large babies) Suggestions in Caring for the Person with COPD EMOTIONAL SUPPORT Accept/encourage expression of emotions. Be an active listener. Be cognizant of conversational dyspnea; do not interrupt or cut off conversations. EDUCATION Teach breathing techniques: •Pursed-lip breathing •Diaphragmatic breathing •Cascade coughing (series) Teach postural drainage. Teach about medications: what, why, frequency, amount, side effects, and what to do if side effects occur. Teach use and care of inhalers and spacers and equipment. Teach signs and symptoms of respiratory infection. Teach about sexual activity: •Sexual function improves with rest. •Schedule sex around best breathing time of day. •Use prescribed bronchodilators 20 to 30 minutes before sex. •Use positions that do not require pressure on the chest or support of the arms. Suggestions for Healthier Living with COPD NUTRITION Eat small, frequent, nutrient-intense meals. Eat foods high in protein and calories. Select foods that do not require a lot of chewing. Have food cut in bite-size pieces to conserve energy. Establish a plan for adequate consumption of fluid; drink 2-3 L of fluid daily (pineapple juice helps cut secretions; keep a liter of water in the refrigerator or on the kitchen counter to be consumed each day in addition to other fluids). PREVENTIVE STRATEGIES Obtain an annual flu vaccination unless contraindicated. Obtain multivalent pneumococcal immunization at intervals directed by health care provider. Notify health care provider of any temperature above 99° F. Examine sputum; recognize and report changes to provider. Do not use over-the-counter drugs unless approved. Xerosis • Extremely dry, cracked, and itchy skin • Occurs primarily in the extremities • Exposure to environmental elements contributes to skin dryness and dehydration. Pruritis • A symptom, not a diagnosis or disease • A threat to skin integrity because of the attempts to relieve it by scratching • Aggravated by perfumed detergents, fabric softeners, heat, sudden temperature changes, gentle touch, pressure, vibration, electrical stimuli, sweating, restrictive clothing, fatigue, exercise, and anxiety Herpes Zoster (Shingles) • A viral infection frequently seen in older adults • Peak incidence occurs between ages 50 and 70. • Immunosuppressed elders and those with histories of chicken pox (varicella) are at greatest risk. • Always occurs along a nerve pathway or dermatome • The majority of the care and treatment of the person with herpes zoster is medical, with prompt initiation of antiviral medications and optimal pain management. • Nursing care includes providing emotional support during the outbreak and education regarding reducing secondary infections and cross-contamination. Basal Cell Carcinoma • Most common malignant skin cancer • Slow-growing and metastasis is rare • Usually begins as a pearly papule with prominent telangiectasis (blood vessels) or as a scar-like area where there is no history of trauma • Early detection and treatment are necessary to minimize disfigurement. Squamous Cell Carcinoma • The second most common skin cancer • Aggressive and has a high incidence of metastasis if not identified and treated promptly • More prevalent in fair-skinned, elderly men who live in sunny climates • Usually found on the head, neck, or hands • Lesion begins as a firm, irregular, fleshy, pink-coloured nodule that becomes reddened and scaly, much like actinic keratosis Melanoma  • A neoplasm of melanocytes • The least common skin cancer • High mortality rate because of its ability to metastasize quickly • Classical, multicolour, raised appearance with an asymmetrical, irregular border • Treatable if caught very early, before it has a chance to invade surrounding tissue ABCDE Rules of Melanoma • Asymmetry: One half does not match the other half. • Border irregularity: The edges are ragged, notched, or blurred. • Colour: The pigment is not uniform in colour, having shades of tan, brown, or black, or a mottled appearance with red, white, or blue areas. • Diameter: The diameter is greater than the size of a pencil eraser or increasing in size. • Evolution: There is a change or “evolution” in size, shape, symptoms, surface, and shades of colour. Skin problems associated with cardiovascular problems Arterial Insufficiency: Peripheral Artery Disease (PAD)  • Often caused by enlarging atherosclerotic plaques • Leads to ischemia of the limb and can lead to severe infections and limb loss • Lower extremity pain can be extreme when walking or when the legs are elevated • Pain is only relieved when the legs are returned to a dependent position or when the person stops walking Venous Insufficiency  • Usually a consequence of a deep vein thrombosis (DVT) • Risk factors • Uncontrolled diabetes • Venous hypertension with impaired functioning of the valves within the veins • Symptoms • Edema of the lower extremity • Brownish discoloration of the skin • Venous ulcer formation Skin problems of particular concern for persons with limited mobility Candidiasis (Candida albicans) • Increased risk • People who are obese, malnourished, receiving antibiotic or steroid therapy, or who have diabetes • Grows especially well in areas that are moist, warm, and dark • Inside the mouth, referred to as “thrush” • On the skin, usually maculopapular, glazed and dark pink in persons with less pigmentation Fungal infection prevention • Limit the conditions that encourage growth • Ensure adequate drying of target areas of the body after bathing • Ensure prompt management of incontinent episodes • Use loose-fitting cotton clothing and cotton underwear • Avoid incontinence products Pressure ulcers: • In Canadian care settings, 25.1% of patients in acute care settings, 29.9% in non-acute care settings, and 15.1% in community care settings had a pressure ulcer. • Complications: • Local infection of wound or surrounding tissue • Loss of function • Tetanus • Extension of the infection to the bone: osteomyelitis • Systemic infection: septicemia • Extended period of acute and continuous medical and nursing care • Risk assessment tools used: The Braden Scale, The Norton Scale Assessment: • Assessment begins with a detailed head-to-toe skin examination and analysis of laboratory findings. • Visual and tactile inspection of the entire skin surface with special attention to bony prominences is essential. • The nurse will look for any interruption of skin integrity or other changes, including redness or hyperemia. • Nail fungus (onychomycosis) o Characterized by degeneration of the nail plate with colour changes to yellow or brown, and opacity, brittleness, and thickening of the nail • Fungal infection of the foot o Tinea pedis Care of the toenails • Toenails should be trimmed after the bath or shower, when they are softened. • Nails should be clipped straight across and even with the top of the toe, with the edges filed slightly. • Diabetic foot care should only be done by a registered nurse (RN) with some experience. Risk factors for Diabetes Mellitus • Prevent progression of the disease • Maintain glycemic control • Target levels for the blood sugar level from 4.4 to 6.1 mmol/L (82 to 110 mg/dL), and glycosylated hemoglobin (Hgb A1c,) at or below 7.0% (CDA, 2008) Interventions for Gerontological Nursing and Healthy Aging • Education and Interventions • Blood pressure ≤ 130/80 mm Hg • Cholesterol < 5.18 mmol/L (200 mg/dL) • Low-density lipoprotein (LDL) < 2.56 mmol/L (100 mg/dL) • High-density lipoprotein (HDL) > 1.03 mmol/L (40 mg/dL) • Triglycerides < 1.69 mmol/L (150 mg/dL) • Blood glucose < 6.11 mmol/L (110 mg/dL) • Assessment • Risk factors • Subjective report of signs and symptoms • Evaluation of the presence or absence of symptoms of hyperglycemia • Polydipsia, polyuria, or polyphagia Session 8:  Coping with chronic health challenges; pain and comfort; and  geropharmacology Prescription drugs and older adults • Older adults get 2-3 times as many prescriptions • 12% of population > 32% of prescription drugs • Avg - $955 per year on drug • Typical older adult takes 4-5 prescriptions and 2 OTC drugs at
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