Nursing Care of Older Adults Exam 2

Age related changes that can predispose people to urinary incontinence
-increased post void residual
-decrease in detrusor contraction
-increased prostate
-relaxation of pelvic muscles
-decreased estrogen in women

Acute reversible causes of incontienece

-Atrophy vaginitis or urethritis
-restricted mobility

Stress incontinenc
leaking associated with activities that increase intra-abdominal pressues

Urge incontinence
feels urge to void and needs to go rapidly, inability to make to bathroom leads to voiding of large amt of urine leakage

most common incontinence among older population
urge incontinence

Overactive bladder continence
associated with urgency,frequency;can be with or without leakage

Overflow incontinence
results in fact that bladder cannot empty due to outlet obstruction or impaired bladder muscle innervations

functional incontinence
incontinence due to mobility difficulties or cognition impairment

Components of incontinence history & physical examination
-medical history
-urological history
-GYN history for women
-Continence hx

Continence history
-voiding pattern
-leaking episodes

Fluids & foods to consider/aviod with incontinence
-fluid intake must be adequate
-artificial sweetness
–tomato based products

Behavioral therapy for incontinence
patient made aware of voiding patters and their actions

Pelvic muscle exercise programs
program to activitely increase pelvic floor muscles strength

Types of incontinence that pelvic muscle exercise programs can help

3 non-pharmalogical nursing interventions to treat incontinence
-behavioral therapies
-pelvic muscle exercise programs

Scheduled toileting program
fixed schedule while patient awake, helpful for urge,stress, void incontinence

prompted toileting program
geared for patients that need staff,caregiver involvement, positive reinforcement, often used in long term care

habit toileting program
toilet schedule based on individuals voiding pattern

Assistive devices for older adults with incontinence
-commode chairs
-bed pan
-female urinal

Medications for Urge incontinence
Oxytrol, Detrol

3 components of normal sleep
-Temporal structure
-Occurs during darkness

2 stages of temporal structure of normal sleep
• Non‐rapid eye movement sleep (NREMS): 75 ‐80% total sleep time
• Rapid eye movement sleep (REMS): 20 – 25% of total sleep time

3 stages of NRES( non rapid eye movement)
– N1 – very light sleep, easily roused – 1‐2%,body jerks
– N2 – begins real sleep, EEG phasic events hallmark sleep – 50%
– N3 – slow wave sleep, not easily awakened

Stage that involves memory consolidation

Rapid Eye movement sleep( REMS)
20-25% of total sleep time
-looks awake on EKG
-active brain on EEG
-memory consolidation,dreams

occurs within set amount of time, uninterrupted sleep

Occurs during darkness
society constrains sleep that requires us to sleep at night, be active during daylight

difficulty getting sleep & maintaining sleep, occurs for 1 month

Consequences of Poor sleep
• -Increased risk for heart attack
• Decreased vaccine effectivesness
• Increased pain and decreased effectiveness of analgeesics
• Increased pain during and after chemo treatment
-increased risk for type II diabetes

Comorbidities that lead to poor sleep

Sleep Wish list for Older Adults
-Sleep for 6-9 hrs
-sleep latency( sleep within 20 min)
-sleep efficacy

Sleep efficacy calculation
total # hours sleep/total # hrs spent in bed

Age related changes in sleep
-more time in bed, less time asleep
-Less N3/NREM & REM
-MOre in N1/N2
-pineal gland atrophy
-phase advanced
-more easily aroused
-less tolerance for phase shifts
-more daytime napping

Sleep Disorders associated with Insomnia
-sleep apnea
-restless leg syndome

Medication with poor sleep as side effect
-thyroid replacement

Lifestyle attributes to poor sleep
-caffeine consumption
-sdentary lifestyle
-alcohol consumption/drugs
-poor sleeping environment

Sleep assessments
-Sleep Dairy
-Sleep inventories

unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage

Acute Pain
pain that serves biological purpose, warning the organisms of disease, injury or threat
• conventional analgesics(opiods, anti-inflammatories)

Persistant Pain
pain that persists long after treatment/injury,ongoing for at least 6 months

Nociceptive Pain
Pain induced by a noxious external stimulus; specialized nerve endings in the skin send this pain message from the skin, through the spinal chord, into the brain.,

inflammatory pain
Pain caused by damage to tissues, inflammation of joints, or tumor cells. This damage releases chemicals that create an “inflammatory soup” that activates nociceptors.

nueropathic pain
peripheral and CNS sensory information is processed abnormally; peripheral and central, mostly unexplained

Consequences of unrelieved pain
-poor sleep
-reduced mobility,quality of life

A sleep disorder characterized by uncontrollable sleep attacks. The sufferer may lapse directly into REM sleep, often at inopportune times.

restless leg syndrome
A condition in which unpleasant sensations in the lower legs are accomanied by an irresistible urge to move the legs, temporarily relieving the unpleasant sensation but disrupting sleep.

Nonpharmacological interventions
-sleep restriction
-relaxation exercises/music
-guided imagery
-aroma therapy
-warm bath

Use of opiods with older adults
act on CNS to inhibit ascending activity and reduce pain
-always initiate a bowel protocol

Maximum daily dose of acetaminophen

Bowel protocol for older adult
-start bulk forming laxative
-stool softener
-increase fiber intake
-drink plenty of fluids

AE of Tricyclic antidepressants in older adults
-cognitive changes
-blurred vision
-dry mouth
-orthostatic hypotension

Key risk factors/contributors to falls
-normal activities at home
-side rails
-physical restraint

fear of falling,decreases mobility & activity—–> sarcopenia/weakness which increases risk of fall

Outcomes of Falls
-Hip fractures

must be observed for 24 hrs if on this medication after TBI, f/u with CT scan

Intrinsic risk factors for impaired mobility
factors within individual- cognitive, physical, acute,sensory, meds

extrinsic risk factors for impaired mobility
within the environment that include risk for fall (lighting, stairs, footwear,restraints)

Institutional risk factors for impaired mobility
staff attitudes, education,inadequate assessment for risk for falls

Outcomes of Presssure ulcers
reduced mobility, poor body image, embarrassment, anger, infection, osteomylitis, renal failure

critical determinants of pressure ulcers
1. intensity & duration of pressure
2. ability of skin & supporting tissue to tolerate pressure

6 factors of pressure ulcers
-skin moisture
-nutritional intake
-friction & shear

intrinsic contributing factors of pressure ulcers
-impaired mobility
-chronic conidtions
exsisting pressure ulcer

external contributing factors to pressure ulcers

surface damage caused by skin rubbing against another surface

-Stress that involves forces moving in opposite direction

Braden scoring for pressure ulcers
Score 1-4 for 6 factor for sensory,activity mobility, skin moisture, nutritional intake, friction,shear(1-3).

Implication of Scoring for Braden scale
15-18: at risk of pressure ulcer
13-14 moderate risk
10-12 high risk
<9 Very High Risk

stage I pressure ulcer
intact skin,epidermis w/ non blanchable redness of localized area over bony prominance. redness does not resolve 30 min after pressure relieved

Stage II pressure ulcer
partial thickness loss of epidermis,shallow open ulcer with red/pink wound bed and no slough

Stage III
full thickness skin loss through dermis, slough/eschar may be present, bone,tendon,muscle not seen

Stage IV
full thickness skin loss, exposed bone, tendon or muscle, slough,eschar,

Unstageable pressure ulcer
full thickness tissue loss in which base of ulcer covered by slough and/ or eschar in wound bed= unable to tell depth of wound

DTI(deep tissue injury)
Suspected deep tissue injury characterized by puple maroon localized area. .INtact skin that is compared to adjacent tissue

Pressure ulcer stages that heal by tissue regeneration
Stage I & II

Pressure ulcers that heal by scar formation & contraction
Stage III & IV

HOw to treat wound infection
-superficial increased bacterial burden
-surrounding skin compartment infection
-deep wound infection or osteomylitis

-remove growth medium
-controls & prevents infection
-defines extend of wound
-stimulates healing process

How to optimize wound environment to promote healing
Manage comorbidities, nutrition, cleanliness, elimination of pain, removal of nonviable tissue, maintain moisture balance, protect wound & periwound skin

Strategies to prevent pressure ulcers
-pressure relief
-reduce friction & shear
-skin care

Factors that affect wound healing
poor blood supply, dehydration,excess exudates, low wound temp, recurrent trauma, infection, necrosis,slough

MCI( Mild Cognitive Impairment)
defines group of patients at high risk for developing dementia

Preclinical dementia
intact cognition & physical fxn

DSM-V criteria for dementia
-loss of cognitive ability
-occurs in normal consciousness
-nuerocognitive disorders

Important cognitive criteria to define dementia
-cognitive change, language, inattention, learning & memory difficulty, decrease in social cognition,praxis

Ability to plan how to execute nonhabitual motor acts and to adapt body movements to complete coordinated, complex movements.

# 1 cause of dementia;a progressive and irreversible brain disorder; characterized by gradual deterioration of memory, reasoning, language, and physical functioning

Vascular dementia
dementia disorder that causes high rates of inflammation,mini strokes that cause slow decline of cognitive function

risk factors for vascular dementia
CHF, HTN, Diabetes, incontinence, cognitive impaired

Frontal lobe dementia
typically affects only frontal lobe, characteristic by agitated profile, impulsivity, inappropriate behaviors

Lewy Body dementia
Dementia with detailed visual hallucinations, altered alertness, and parkinsonian symptoms

Early onset dementia
rapidly progressive, starts as early as age 50, rare and familial form of dementia

Korsakoff dementia
acute chronic dementia usually caused by heavy alcohol use, drugs

Different causes of delerium
drugs, depression, hypothyroidism, infection,tumor, vitmain deficiences, normal pressure hydrocephalalus

short tem memory, inability to establish new memories

movemtn, coordination difficulty

trouble recognizing objects, faces

Characteristics of Mild stage of dementia
personality changes, caluclation problems, communication,judgement issues, daily living tasks are harder

Characteristics of Moderate stage of dementia
memory loss increase, sleep disturbances, gets lost easily, needs help with ADLs, agitated behaviors due to frustrations

Characteristics of Severe stage of dementia
motor skills loss, incontinence, does not recognize self or family, dependent, swallowing difficulties

Pharmacological Treament for Dementia
– Rivastigmine(Excelon)

Nursing interventions for mild cognitive impairment
encourage healthy, diet/living, stress reducers, educate on disease process, cognitive stimulation

Nursing interventions for early stage dementia
provide structure, support /education for caregiver, redesign home

Nursing interventions for Advance stage of dementia
End of life care, muscic therapy, patience

Criteria for Acute Confuctional State( delirium)
-disturbance to LOC
-sudden change of cognition
-acute onset fluctuation
-precipitated by some insult
-occurs in patients with baseline confusion

Precipitating Factor sfor delerium
-infections( UTI, URI, cellulitis)
-glucose abnormalities
-acute illness( organ failure)
-environment( new setting, high sensory input

Methods for assessing delirium
CAM method
Delerium O’Meter

Treatment approaches for addressing delirium in older adult
-identify & treat reversible contributors
-maintain behavior control
-anticipate and prevent complication
-restore function

Drugs to reduce & eliminate when treating delerium
-alcohol,anticholinergics, anticonvulsants, antidepressants, barbituates, opids, antipsychotics

Symptoms of depression
-depressed mood, agitation, anhedonia, change in weight, sleep change, feelings of low worth/hope, diminished ability to concentrate

Overlapping symptoms to depression & dementia
-memory problems
-decreased activity & quality of life

Screening tools for depression
-Geriatric Depression Scale
-Beck depression inventory
-Hamiltation Rating Scale for Depression
-Patient health Questionaire
-Whooley Depression Screens

Treatments for depressed patients
-CBT, enpowerment training, pharmocotherapy, psychotherapy, ECT, educate caregivers, community resources

Key aspects of a fall and fall/safety assessment
-review of intrinsic risk factors
-review of extrinsic risks
-history recurrent falls
-fear of falling
-post fall assessment

Post Fall Assessments
-Hopkins Fall
-Hendrichs Fall
-Post fall assessment

Problems with fall risk assessments
-assessment do not lead to interventions
-nurses desentize high scores
-clinical judgement not considered

Factors that mobility is dependent on
-age related changes
-muscle strength
postural stability
vibratory sensation

Gait changes in older adults
-narrowed base
-increased sway
-decreased step height
-decreased arm swing
-slowed responses
-increased care w/gait

Risk factors for impaired mobility
-Disease states
-age related changes
-treatment r/t factors
-lifestyle related factors
-psychological factors

Measurement methods for predicting mobility
-walking speed
-chair stands
-TUG/Get up & go

Methods for conducting ADLs functional assessment
2.Barthel Index

First line tool for assessing subjective sleep patterns &sleep quality
Sleep diaries

Purpose for insomnia drugs that have rapid onset, short acting
Difficulty falling asleep

Purpose for longer duration drugs for insomnia
Difficulty staying asleep

Examples of drugs to treat insomnia with longer duration
Quezapam, zolpidem

Transcutaneous electrical nerve stimulation

Cloudiness of the lens of the eye; decreased acuity; progressively blurred vision; both central and peripheral; glare sensitivity

macular degeneration
A vision disorder caused by deterioration of the central portion of the retina and marked by loss or distortion of the central field of vision.

An eye disease in which the intraocular pressure is high enough to cause damage to the optic nerve, resulting in visual loss; caused by impaired drainage of the aqueous fluid out of the eye

components of cognitive assessment
-complete comprehensive assessment
-formal cognitive testing

conductive hearing loss
Mechanical dysfunction or obstruction of the external/middle ear.Usually caused by cerumen impaction

sensorineural hearing loss
Hearing loss caused by damage to cochlea receptor cells or auditory nerves (“nerve deafness”)

A form of sensorineural hearing loss that occurs as a function of age and is usually associated with a decrease in the ability to hear high frequencies.

Communication strategies for those with hearing impairments
-face them at same level
-articulate well w/ moderate speed in low tone
-reduce background noise
-provide assistive devices if needed
-control lighting

common cause of hearing impairment in older adults- consists of constant ringing, whistling or booming noise

Intervention for caring for adults with visual impairments
• use warm, incandescent lighting
• increase intensity of lighting
• suggest yellow or amber lenses to decrease glare and sunglasses to block UV light
• Recommend reading material that have large dark evenly spaced printing
• Choose primary colors to assist those with partial sight

Low vision assistive devices
-insulin delivery systems
-talking clocks/watches
-large print books
-software that converts text into artifical voice output

Communication strategies with the vision impaired
– make sure you have the patient’s attention
– introduce yourself each time you enter, state when you are leaving as well
– get down to the person’s level and face them when speaking
– Speak normally, without raising or lowering your voice
– Ensure adequate lighting and eliminate glare
– Use analog of clock to help locate objects
– Select colors of rich intensity/contrast

3 major types of verbal communication impairements that arisse from nuerological disturbances

impaired by anxiety,or related to specific disorder,hearing deficits, or altered LOC

distorted by stroke,dementia,and delirium

hampered by mechanical difficulties such as dysarthia, respiratory disease, destruction of the larynx and strokes

word retrieval difficulties during spontaneous speech and naming tasks

communication disorder that can affect a persons ability to use and understand spoken or written words

fluent aphasia
result of lesion in Wernicke’s area. Person speaks easily but words do not make sense

non fluent aphasia
damage to Broca’s area.Ability to understand others,speaks slow with minimal words due to articulation struggles. lost in ability to control movements of speech

Verbal praxia
affects ability to plan and sequence voluntary muscle movements.Struggles to say words, may be nonverbal

Anomic aphasia
severe word finding difficulty, inability to find words, name objects-easily frusturated

Global apasia
large L. Hemisphere lesions resulting in cannot understand words or speak intelligentably.Use meaningless syllables repeatibly

speech disorder caused by weakness or incoordination of speech muscles

Characteristics of speech in dysarthria
words jerky, slurred, lacking expression,difficult to understand

Questions to ask to determine receptive abilities
•Can patient understand yes/no choice?
•Can patient read simple instructions?
•Can patient understand simple verbal instructions?
•Can patient understand instruction with physical cues?
•Can patient make a choice when presented with two objects or options?

Questions to ask to determine Expressive abilities
•Does the patient have difficulty finding the correct word?
•Does the patient have difficulty creating sentences or a logical flow of ideas?
•Does the patient curse, use offensive or aggressive language, or exhibit aggressive or combative behaviors?

Methods to reduce friction & shear
-use of draw sheet
-elevate HOB,FOB
-use pillows for hip/lateral support

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