1. Frailty/ Safety
1.1. Accidents are 6th leading cause of death; Falls leading cause of injury r/t
1.1.1. Pneumonia and influenza 4th COD
1.1.2. Gastroenteritis caused by salmonella is freq
1.1.3. UTI frequency inc with age
1.1.4. 35%-40% of 65yo fall each year; ½ have multiple falls
1.1.5. Falls leading COD fatal and nonfatal injuries
1.2. Delayed diagnosis of infection contribute to higher mortality rate from infection
1.3. Ensure macro and micro environment are easily manipulated, organized, easily maneuverable by pt
1.3.1. Natural, bright lighting, 75F or above room temperature, low noise level, simple wall coverings that differ room to room- red, yellow, white (stim BP), blue, brown, earth tones (relax), orange (stem appetite), violet (repress appetite) green (healing) black and gray (depressing). No small area rugs, non glare surface
1.3.2. No extreme weather (not above 106F, low pollution, low traffic, natural resources available
1.3.2.1. diabetes and cerebral atherosclerosis high risk for hyperthermia
1.4. "Sensory stimulation box" contains objects of different textures, color, smells to provide activity
1.5. Shower seats and grab bars, non slip rug in shower
1.6. Educate on fire hazards, use of smoke detectors, CO2 detectors, stay in kitchen when stove or oven is on, clean wood-burning fireplaces
1.7. Restraints can lead to injury like aspiration, circulatory obstruction, cardiac stress, skin tears and ulcers, anorexia, dehydration, incentive, fractures, dislocations
1.7.1. Place in room close to nursing station, one on one supervision, bed alarms, comfort measures enforced, freq reality orientation, diversional activities
2. Nursing strategies
2.1. Nutrition— get health and family history, examine skin hair nails and movement w oral and sensory organs, obtain blood sample, measure body skin folds and arm circumference, psychological exam
2.1.1. Mini Nutritional Assessment
2.1.2. Promote good oral health- look for bleeding gums, painful gums, pus at gum line, chronic bad breath, loose teeth
2.2. Sleep: assess quality and quantity of sleep, educate to avoid caffeine and alcohol at bed time, educate medications that affect sleep and sleep pattern
2.2.1. Pittsburgh sleep index
2.2.2. Record sleep pattern, ask about pain, diet, ADL, home life
2.3. Sexual Health: sex history and concerns or problems existing, lab tests, review medications. Ensure adult is educated on safe sex especially with multiple partners or a new partner, STI, use of condoms
2.4. Safety: Hendrich II Fall Risk Model, assess risk of injury per patient, identify high risk patients, encourage to wear glasses and hearing aids, ensure there are wheelchairs walkers, avoid physical and chemical restraints, advice pt to move slowly to prevent falls, keep floor keep, good lighting, store cleaning products in safe area, assist with transfers and encourage to use grab bars, review medications w pt, ensure well-fitted clothing, review home safety, refer to social services if needed
2.4.1. Ensure vaccines are up tp date (pneumonia and flu)
3. Polypharmacy
3.1. Risks include adverse effects and accidents resulting from drowsiness and dizziness
3.2. Common drugs: CV agents, antihypertensives, analgesics, anti arthritic agents, sedatives, tranquilizers, laxatives, antacids
3.2.1. Adverse effects: confusion, dizzy, falls, fluid electrolyte imbalance
3.3. high caffeine intake can decrease effects of antiarrhythmics, cimetidine, iron, methotrexate; heighten hypokalemic effects, inc stimulant effects of amantadine, decongestant, fluoxetine, theophylline
3.4. protein-bound drugs achieve desired result because ineffective binding to reduce protein molecules
3.5. dehydration and hypoalbumenemia dec drug distribution and result higher drug levels in blood
3.5.1. dehydration, hyperthermia, immobility, liver disease dec ,metabolism of drugs--toxic levels can accumulate
3.5.1.1. Beers criteria**
4. Delirium and Dementia
4.1. Delirium alters LOC
4.1.1. Delirium caused by disruption in brain function dt medication side effect, circulatory disruption, dehydration, HTN, low or high thyroid activity, low or high blood glucose, surgery, stress
4.1.2. onset is rapid, change noted within day or days
4.1.3. short term memory impaired, disorientation, confusion, incoherent speech, suspicious of other, exaggeration in personality features, hallucinations
4.1.4. can be hyperactive or hypoactive (agitated or dull)
4.1.5. Treatment with reversal of cause is treated promptly
4.1.5.1. Nursing cognitive testing: Mini COG & CAM (COG- item recall, draw simple clock) (Confusion assessment method- thinking questions, score gives results)
4.2. Dementia does not alter LOC
4.2.1. damage to brain tissue dt Alzheimers disease, lack of oxygen, infection, trauma, hydrocephalus, tumors, alcoholism, etc
4.2.1.1. diagnosis and staging important for treatment and early detection of Alzheimers (caused by extra chromosome 21, free radicals higher than normal in brain cells, low zinc levels
4.2.2. slow onset, detect in months to years before symptoms
4.2.3. poor short and long term memory, disorientation, confusion, difficulty finding proper word to use, impaired judgement, problems in math, personality changes
4.2.4. behavior becomes inappropriate, unsteady feet, difficulty coordinating
4.2.5. progressive disease may be slowed but can not be cured-- continues to worsen
4.2.6. risk for suicide in early stages of disease
5. Cardiovascular
5.1. Decreased reserve
5.2. No change at rest in HR, CO
5.3. Under stress: dec. HR, CO cause fatigue, SOB
5.4. Risk of isolates says hypertension, inflamed varicosites
5.5. Risk of arrhythmias, postural hypotension, may cause syncope
6. Sensory organs
6.1. Vision
6.1.1. Loss of elasticity in lens- thicken
6.1.2. Decrease lens focus for near objects
6.1.3. Decrease adapt to light
6.1.4. Diseases: cataracts, macular degeneration, glaucoma, diabetic retinopathy, htn retinopathy, temporal arthritis, detached retina
6.2. Hearing
6.2.1. Presbycusis: loss of high frequency, loss of hair cells, Fibrous changes in small blood vessels
6.2.2. Conductive hearing loss: cerumen impaction or fireign object, ruptured ear drum, otitis media, otosclerosis
6.2.3. Sensorineural hearing loss: damage to inner ear, cochlea, fibers of 8th CN, hereditary , viral, bacterial, trauma, tumors, noise, CV condition, ototoxic and Ménière’s disease
6.2.4. Diseases: central auditory processing disorder, tinnitus ( ringing), Ménière’s disease
6.3. Smell and taste
6.3.1. Decline sensitivity to airborne chem stimuli
6.3.2. Decrease ability to detect sweet foods
6.3.3. Diseases: burning mouth syndrome ( vit b deficiencies, local trauma, GI disorder causing reflux, allergies, salivary dysfunction, diabetes)
6.4. Peripheral sensation
6.4.1. Sense of touch declines
6.4.2. Two point discrimination and vibratory sense decrease
6.4.3. Ability to perceive painful stim, slow rx time
6.4.4. Diseases: peripheral neuropathy, diabetic neuropathy, phantom limb pain, acute sensory loss
7. Pulmonary
7.1. Reduced reserve
7.1.1. At rest: no change
7.1.2. With exertion: dyspnea, dec. exercise tolerance
7.2. Dec chest expansion (12-24rr)
7.3. Dec cough/mucus clearance
7.4. Inc risk of infection and bronchospasm w airway obstruction
8. Reproductive
8.1. Female
8.1.1. Hormonal change cause vulva to atrophy
8.1.2. Uterus, cervix, ovaries decrease in size
8.1.3. Vagina drier and more alkaline
8.1.4. Breast sag and less firm after menopause
8.2. Male
8.2.1. Reduce sperm count- seminal vehicle thinner
8.2.2. Testes atrophy
8.2.3. Enlarge prostate gland
8.3. Diseases: vaginitis, cancer of vagina, cancer of cervix, endometrium, and ovaries, Perineal herniation, dyspareunia, cancer of breast. Erectile dysfunction, BPH, cancer of prostate, tumors of one is, testes, scrotum.
9. Gastrointestinal
9.1. Risk of chewing impairment, fluid imbalance, poor nutrition
9.2. Altered drug absorption, inc risk of GERD, maldigestion, NSAID ulcers
9.3. Constipation is not normal
9.4. Risk for fecal incontinence w disease (not normal)
9.5. Stable liver function tests— risk for adverse drug rx
9.6. Esophageal and stomach motility decrease
9.7. Decreased elasticity of stomach
9.8. Stomach has higher pH— d/t decline hydrochloride acid and pepsin
9.9. Weak gag reflex
10. Endocrine
10.1. Decrease thyroid land activity cause low basal metabolic rate
10.2. Significant reduce T3
10.3. ACTH decrease from adrenal gland
10.4. Pituitary gland decrease 20% in size
10.5. Decreased follicle stim hormone, LH, luteotropic hormone, gonadal secretion
10.6. Delay in release of insulin by beta cells and pancreas
11. Musculoskeletal
11.1. Sarcopenia, inc risk disability, falls, unstable gait
11.2. Risk osteopenia and osteoporosis, osteoarthritis
11.3. Limited ROM, joint instability
12. Nervous
12.1. Impairment in general strength, deep-tendon reflex, nerve conduction velocity, slowed motor skills, deficit in balance and coordination
12.2. Decreased temperature sensitivity
12.3. Slowed speed of cognitive processing, most memory function adequate for normal life
12.4. Inc risk of sleep disorder, delirium, neurodegenerative disease
13. Integumentary
13.1. Reduce thickness and vascular it of dermis
13.2. Collagen fibers coarser and random
13.3. Reduce skin elasticity, more dry, more fragile
13.4. Less subQ fat
13.5. 10-20% less melanocytes - benign and malignant neoplasms occur more w age
13.6. Scalp, pubic, armpit hair thin and gray
13.7. Most men bald by 50yrs old
13.7.1. Increase brow, ear, nostril hair
13.8. Finger nails grow slowly and brittle w striations
13.9. Perspiration slightly reduced w sweat glands
14. Urinary
14.1. Reduced reserve, risk for illness
14.2. Risk of nephrotoxic injury and adverse drug rx
14.3. Risk of volume overload (in HF), dehydration, hyponatremia, hypernatremia, hyperkalemia, reduc acid load
14.4. Inc risk of urgency, incontinence, UTI, nocturnal polyuria—potential for falls
15. Sleep
15.1. More likely to fall asleep earlier in evening and awake early morning—-phase advance
15.2. Daytime naps more frequent
15.3. Increase natural light to improve circadian rhythm
15.3.1. More likely to awaken with light, noise, change in room temp
15.4. Sleep less soundly—in and out of stage I, more time in stage I and II, decline time in stages III, IV
15.5. Diseases: insomnia, nocturnal myoclonus and restless leg syndrome, sleep apnea.
15.5.1. Conditions affect sleep: cardiac ischemia, fluctuating bl glucose gastric pain, COPD, musculoskeletal pain, dementia, depression, etc
15.5.2. Poor quality sleep= more likely for suicide
15.6. Regular exercise, Melatonin, valerian root tea, protein or carb snack 45 min before bed to for sedating effect
16. Reproductive/ Sexual Human Needs
16.1. Decrease in sexual responsiveness reduce frequency orgasm
16.2. Men slower to erect, mount, ejaculate
16.3. Women may have dyspareunia (painful sex)
16.4. Women gain sex interest
16.5. Menopause occurs for at least 1 year, around 5th decade of life—-estrogen levels fall reduce ovarian follicles
16.5.1. Symptoms: hot flashes, fatigue, migraines, arthritis, heart palpitations, restless leg syndrome, vaginal dryness, insomnia, dec met rate, inc fat on hips and stomach, UTI symptoms, bladder and vag infections, inc risk of osteoporosis heart disease and color cancer, moodiness, depression, fuzzy thinking, lack of concentration, impatience, anxiety, paranoia
16.5.1.1. Control: acupuncture, diet (foods high in estrogen, boron, avoid adrenal-stim foods like alcohol caffeine carbs salt sugar), exercise, imagery, mediation, vaginal lubrications, regular sleep, stress management, T’ai chi, vaginal moisturizers (st johns wort, licorice root, wild yam), vitamins and minerals, yoga
16.6. AIDS seen 50% more in older gen d/t lack of sex education
16.7. Spinal cord stenosis- create probs w sex function- age relate degenerative disorder
16.8. Erectile dysfunction affect over ½ men over 70yo—manage w viagra, Levitra, cialis
16.9. BPH symptom- hesitancy w urination, dec flow of stream, nocturia
17. Nutrition/ Exercise
17.1. Less lean body mass and increases adipose issue- not burn cals quickly
17.2. Basal met rate decrease 2% each decade after 25yo
17.3. Activity level decrease
17.4. *Harris-Benedict equation used to figure resting calorie needs—quantity monitoring
17.5. *Limit fat intake to less than 30% of total cals—quality monitoring
17.5.1. 5 servings fruit and veg daily
17.6. Soluble Fiber is important to consume: oats, pectin—lower cholesterol, improve glucose tolerance, prevent obesity, CV health, colorectal disease
17.7. Limit Carbohydrates to maintain reg. Glucose level
17.8. 1g protein per kg of body weight —10-20% of daily caloric from protein
17.9. Ensure adequate calcium and vitamin D
17.9.1. Niacin, riboflavin, thiamine, vit b6, vit C, vit D- common deficiencies
17.9.2. Calcium Supplement for post-menopausal at least 1000mg
17.10. Recommended—3.7L/2.7L of water a day unless contraindicated by nausea, incontinence, altered cognition, etc...
17.11. Diseases: constipation, malnutrition, dysphasia, anorexia
17.12. Oral health affects everybody system—problems should be identified and addressed promptly
17.12.1. Dysphasia inc with age, can occur in mouth to esophagus (transfer) down esophagus (transport) esophagus to stomach (delivery)
17.12.2. Caused by Stroke and GI reflux
17.12.3. thickened food and beverage may be necessary; small bites
17.12.3.1. ensure bed is upright when pt is eating or resting
17.12.3.2. keep suction machine close
18. Immune
18.1. Increased susceptibility to infection
18.2. Reduced efficacy of vaccination, chronic inflammatory state
18.3. Fever blunted or absent in very old, frail older adults
18.3.1. Baseline oral is 97.4F