1. Gastrointestinal
1.1. Risk of chewing impairment, fluid imbalance, poor nutrition
1.2. Altered drug absorption, inc risk of GERD, maldigestion, NSAID ulcers
1.3. Constipation is not normal
1.4. Risk for fecal incontinence w disease (not normal)
1.5. Stable liver function tests— risk for adverse drug rx
1.6. Esophageal and stomach motility decrease
1.7. Decreased elasticity of stomach
1.8. Stomach has higher pH— d/t decline hydrochloride acid and pepsin
1.9. Weak gag reflex
2. Cardiovascular
2.1. Decreased reserve
2.2. No change at rest in HR, CO
2.3. Under stress: dec. HR, CO cause fatigue, SOB
2.4. Risk of isolates says hypertension, inflamed varicosites
2.5. Risk of arrhythmias, postural hypotension, may cause syncope
3. Urinary
3.1. Reduced reserve, risk for illness
3.2. Risk of nephrotoxic injury and adverse drug rx
3.3. Risk of volume overload (in HF), dehydration, hyponatremia, hypernatremia, hyperkalemia, reduc acid load
3.4. Inc risk of urgency, incontinence, UTI, nocturnal polyuria—potential for falls
4. Immune
4.1. Increased susceptibility to infection
4.2. Reduced efficacy of vaccination, chronic inflammatory state
4.3. Fever blunted or absent in very old, frail older adults
4.3.1. Baseline oral is 97.4F
4.4. Symptoms: decline mental status, dec appetite, incontinence, falls, fatigue, exacerbation of illness
5. Nervous
5.1. Impairment in general strength, deep-tendon reflex, nerve conduction velocity, slowed motor skills, deficit in balance and coordination
5.2. Decreased temperature sensitivity
5.3. Slowed speed of cognitive processing, most memory function adequate for normal life
5.4. Inc risk of sleep disorder, delirium, neurodegenerative disease
6. Endocrine
6.1. Decrease thyroid land activity cause low basal metabolic rate
6.2. Significant reduce T3
6.3. ACTH decrease from adrenal gland
6.4. Pituitary gland decrease 20% in size
6.5. Decreased follicle stim hormone, LH, luteotropic hormone, gonadal secretion
6.6. Delay in release of insulin by beta cells and pancreas
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. Musculoskeletal
8.1. Sarcopenia, inc risk disability, falls, unstable gait
8.2. Risk osteopenia and osteoporosis, osteoarthritis
8.3. Limited ROM, joint instability
9. Reproductive
9.1. Female
9.1.1. Hormonal change cause vulva to atrophy
9.1.2. Uterus, cervix, ovaries decrease in size
9.1.3. Vagina drier and more alkaline
9.1.4. Breast sag and less firm after menopause
9.2. Male
9.2.1. Reduce sperm count- seminal vehicle thinner
9.2.2. Testes atrophy
9.2.3. Enlarge prostate gland
9.3. 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.
10. Integumentary
10.1. Reduce thickness and vascular it of dermis
10.2. Collagen fibers coarser and random
10.3. Reduce skin elasticity, more dry, more fragile
10.4. Less subQ fat
10.5. 10-20% less melanocytes - benign and malignant neoplasms occur more w age
10.6. Scalp, pubic, armpit hair thin and gray
10.7. Most men bald by 50yrs old
10.7.1. Increase brow, ear, nostril hair
10.8. Finger nails grow slowly and brittle w striations
10.9. Perspiration slightly reduced w sweat glands
11. Sensory organs
11.1. Vision
11.1.1. Loss of elasticity in lens- thicken
11.1.2. Decrease lens focus for near objects
11.1.3. Decrease adapt to light
11.1.4. Diseases: cataracts, macular degeneration, glaucoma, diabetic retinopathy, htn retinopathy, temporal arthritis, detached retina
11.2. Hearing
11.2.1. Presbycusis: loss of high frequency, loss of hair cells, Fibrous changes in small blood vessels
11.2.2. Conductive hearing loss: cerumen impaction or fireign object, ruptured ear drum, otitis media, otosclerosis
11.2.3. 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
11.2.4. Diseases: central auditory processing disorder, tinnitus ( ringing), Ménière’s disease
11.3. Smell and taste
11.3.1. Decline sensitivity to airborne chem stimuli
11.3.2. Decrease ability to detect sweet foods
11.3.3. Diseases: burning mouth syndrome ( vit b deficiencies, local trauma, GI disorder causing reflux, allergies, salivary dysfunction, diabetes)
11.4. Peripheral sensation
11.4.1. Sense of touch declines
11.4.2. Two point discrimination and vibratory sense decrease
11.4.3. Ability to perceive painful stim, slow rx time
11.4.4. Diseases: peripheral neuropathy, diabetic neuropathy, phantom limb pain, acute sensory loss
12. Nutrition/ Exercise
12.1. Less lean body mass and increases adipose issue- not burn cals quickly
12.2. Basal met rate decrease 2% each decade after 25yo
12.3. Activity level decrease
12.4. *Harris-Benedict equation used to figure resting calorie needs—quantity monitoring
12.5. *Limit fat intake to less than 30% of total cals—quality monitoring
12.5.1. 5 servings fruit and veg daily
12.6. Soluble Fiber is important to consume: oats, pectin—lower cholesterol, improve glucose tolerance, prevent obesity, CV health, colorectal disease
12.7. Limit Carbohydrates to maintain reg. Glucose level
12.8. 1g protein per kg of body weight —10-20% of daily caloric from protein
12.9. Ensure adequate calcium and vitamin D
12.9.1. Niacin, riboflavin, thiamine, vit b6, vit C, vit D- common deficiencies
12.9.2. Calcium Supplement for post-menopausal at least 1000mg
12.10. Recommended—3.7L/2.7L of water a day unless contraindicated by nausea, incontinence, altered cognition, etc...
12.11. Diseases: constipation, malnutrition, dysphasia, anorexia
12.12. Oral health affects everybody system—problems should be identified and addressed promptly
12.12.1. Dysphasia inc with age, can occur in mouth to esophagus (transfer) down esophagus (transport) esophagus to stomach (delivery)
12.12.2. Caused by Stroke and GI reflux
12.12.3. thickened food and beverage may be necessary; small bites
12.12.3.1. ensure bed is upright when pt is eating or resting
12.12.3.2. keep suction machine close
13. Reproductive/ Sexual Human Needs
13.1. Decrease in sexual responsiveness reduce frequency orgasm
13.2. Men slower to erect, mount, ejaculate
13.3. Women may have dyspareunia (painful sex)
13.4. Women gain sex interest
13.5. Menopause occurs for at least 1 year, around 5th decade of life—-estrogen levels fall reduce ovarian follicles
13.5.1. 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
13.5.1.1. 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
13.6. AIDS seen 50% more in older gen d/t lack of sex education
13.7. Spinal cord stenosis- create probs w sex function- age relate degenerative disorder
13.8. Erectile dysfunction affect over ½ men over 70yo—manage w viagra, Levitra, cialis
13.9. BPH symptom- hesitancy w urination, dec flow of stream, nocturia
14. Sleep
14.1. More likely to fall asleep earlier in evening and awake early morning—-phase advance
14.2. Daytime naps more frequent
14.3. Increase natural light to improve circadian rhythm
14.3.1. More likely to awaken with light, noise, change in room temp
14.4. Sleep less soundly—in and out of stage I, more time in stage I and II, decline time in stages III, IV
14.5. Diseases: insomnia, nocturnal myoclonus and restless leg syndrome, sleep apnea.
14.5.1. Conditions affect sleep: cardiac ischemia, fluctuating bl glucose gastric pain, COPD, musculoskeletal pain, dementia, depression, etc
14.5.2. Poor quality sleep= more likely for suicide
14.6. Regular exercise, Melatonin, valerian root tea, protein or carb snack 45 min before bed to for sedating effect
15. Delirium and Dementia
15.1. Delirium alters LOC
15.1.1. 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
15.1.2. onset is rapid, change noted within day or days
15.1.3. short term memory impaired, disorientation, confusion, incoherent speech, suspicious of other, exaggeration in personality features, hallucinations
15.1.4. can be hyperactive or hypoactive (agitated or dull)
15.1.5. Treatment with reversal of cause is treated promptly
15.1.5.1. Nursing cognitive testing: Mini COG & CAM (COG- item recall, draw simple clock) (Confusion assessment method- thinking questions, score gives results)
15.2. Dementia does not alter LOC
15.2.1. damage to brain tissue dt Alzheimers disease, lack of oxygen, infection, trauma, hydrocephalus, tumors, alcoholism, etc
15.2.1.1. 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
15.2.2. slow onset, detect in months to years before symptoms
15.2.3. poor short and long term memory, disorientation, confusion, difficulty finding proper word to use, impaired judgement, problems in math, personality changes
15.2.4. behavior becomes inappropriate, unsteady feet, difficulty coordinating
15.2.5. progressive disease may be slowed but can not be cured-- continues to worsen
15.2.6. risk for suicide in early stages of disease
16. Frailty/ Safety
16.1. Accidents are 6th leading cause of death; Falls leading cause of injury r/t
16.1.1. Pneumonia and influenza 4th COD
16.1.2. Gastroenteritis caused by salmonella is freq
16.1.3. UTI frequency inc with age
16.1.4. 35%-40% of 65yo fall each year; ½ have multiple falls
16.1.5. Falls leading COD fatal and nonfatal injuries
16.2. Delayed diagnosis of infection contribute to higher mortality rate from infection
16.3. Ensure macro and micro environment are easily manipulated, organized, easily maneuverable by pt
16.3.1. 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
16.3.2. No extreme weather (not above 106F, low pollution, low traffic, natural resources available
16.3.2.1. diabetes and cerebral atherosclerosis high risk for hyperthermia
16.4. "Sensory stimulation box" contains objects of different textures, color, smells to provide activity
16.5. Shower seats and grab bars, non slip rug in shower
16.6. Educate on fire hazards, use of smoke detectors, CO2 detectors, stay in kitchen when stove or oven is on, clean wood-burning fireplaces
16.7. Restraints can lead to injury like aspiration, circulatory obstruction, cardiac stress, skin tears and ulcers, anorexia, dehydration, incentive, fractures, dislocations
16.7.1. Place in room close to nursing station, one on one supervision, bed alarms, comfort measures enforced, freq reality orientation, diversional activities
17. Polypharmacy
17.1. Risks include adverse effects and accidents resulting from drowsiness and dizziness
17.2. Common drugs: CV agents, antihypertensives, analgesics, anti arthritic agents, sedatives, tranquilizers, laxatives, antacids
17.2.1. Adverse effects: confusion, dizzy, falls, fluid electrolyte imbalance
17.3. high caffeine intake can decrease effects of antiarrhythmics, cimetidine, iron, methotrexate; heighten hypokalemic effects, inc stimulant effects of amantadine, decongestant, fluoxetine, theophylline
17.4. protein-bound drugs achieve desired result because ineffective binding to reduce protein molecules
17.5. dehydration and hypoalbumenemia dec drug distribution and result higher drug levels in blood
17.5.1. dehydration, hyperthermia, immobility, liver disease dec ,metabolism of drugs--toxic levels can accumulate
17.5.1.1. Beers criteria**
18. Nursing strategies
18.1. 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
18.1.1. Mini Nutritional Assessment
18.1.2. Promote good oral health- look for bleeding gums, painful gums, pus at gum line, chronic bad breath, loose teeth
18.2. Sleep: assess quality and quantity of sleep, educate to avoid caffeine and alcohol at bed time, educate medications that affect sleep and sleep pattern
18.2.1. Pittsburgh sleep index
18.2.2. Record sleep pattern, ask about pain, diet, ADL, home life
18.3. 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
18.4. 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
18.4.1. Ensure vaccines are up tp date (pneumonia and flu)