Gerontologic Nursing Strategies

Strategies for Gerontologic Nursing

• Normal physiological changes can lead to increased residual urine and consequently UTIs.
• Chewing problems in older adults may result in aspiration and nutrition problems.
• Constipation can be addressed through increased activity, fluid intake, and fiber consumption.
• Need to know the signs and symptoms of conditions
• Atypical presentations of conditions are likely
• It is important to focus on nursing intervention for acute and chronic diseases

Medication Considerations

• Safety precautions and awareness of adverse reactions are critical when administering medications.
• Polypharmacy is a common concern.
• "Start low, go slow" approach is recommended.
• Aspiration risk should always be considered during medication administration.
• Enteric-coated medications should be swallowed whole.

Safety and Aging Theories

• Awareness of signs of abuse is vital for safety precautions.
• The disengagement theory is one of the aging theories.

The Biological Theory of Aging

• Aging is thought to be caused by the accumulation of damage to DNA, proteins, and lipids in cells by free radicals.
• Free radicals have incompatible internal electrical charges that damage tissues; they are in all environments surrounding people.
• Nursing implications include preventing conditions that promote the appearance of free radicals by maintaining proper nutrition and limiting stress.
• The immunological theory posits that aging is due to a decline in the immune system that leads to worsened protective functions and infections.
• Nursing implications involve encouraging healthy activity, proper alcohol and drug use, and medications that support a healthy immune system.

The Disengagement Theory Definition

• People age by accepting less functions that they did in the past
• Ageing is linked to less: time, money and friends
• Over time aging becomes acceptable

Nursing Implications of the Disengagement Theory

• Support and improve the quality of life.
• Provide necessary activity programs.
• Support social connections.
• Help adaptation to changes.

The Sociological Theory

• Aging stems from changes in societal roles.
• Aging is a transition from one role to another.
• Nursing implications include helping patients transition to new roles and environments.

The Discrimination Theory

• Assumes aging results in negative stereotypes, social isolation, and poverty.
• Nursing implications include creating an environment with policies to prevent age-based biases and support patients' rights and access.

Categories of Aging

• Young-old: 60-74 years
• Middle-old: 75-84 years
• Old-old: >85 years
• Over 100 years

Care of Older Client

• Aging is a biopsychosocial process of change between birth and death.
• Gerontology is the study of the aging process.

Integumentary system Physiological Changes

• Loss of pigment in hair and skin.
• Wrinkling of the skin and thinning of the epidermis.
• Easy bruising and tearing of the skin
• Decreased skin turgor, elasticity, and subcutaneous fat.
• Increased nail thickness and decreased nail growth.
• Decreased perspiration, dry, itchy, scaly skin.
• Seborrheic dermatitis and keratosis formation lead to overgrowth and thickening of the skin.

Neurological System Physiological Changes

• Slowed reflexes, slight tremors, and difficulty with fine motor movement.
• Loss of balance and increased incidence of awakening after sleep onset.
• Increased susceptibility to hypothermia and hyperthermia.
• Short-term memory decline is possible, with long-term memory usually maintained.

Musculoskeletal System Physiological Changes

• Decreased muscle mass and strength, atrophy of muscles.
• Decreased mobility, range of motion, flexibility, coordination, and stability.
• Change of gait with shortened step and wider base leading to an increased risk of falls
• Posture and stature changes cause a decrease in height and increased brittleness of the bones with age
• Deterioration of components of joint capsule
• Kyphosis of the dorsal spine (increased convexity in the curvature of the spine) is common.

Falls and Osteoporosis

• Neurological and musculoskeletal system changes cause older clients to be at a higher risk of falls.

Cardiovascular System Physiological Changes

• Diminished energy and endurance with lowered tolerance to exercise.
• Decreased compliance of the heart muscle, with heart valves becoming thicker and more rigid.
• Decreased cardiac output and decreased efficiency of blood return to the heart.
• Decreased compensatory response, resulting in a decreased ability to handle demands on the cardiovascular system.
• Weak peripheral pulses, increased blood pressure, and postural hypotension increase.
• Resting heart rate will decrease

Respiratory System Physiological Changes

• Decreased stretch and compliance of the chest wall leading to:
• Decreased strength and function of respiratory muscles
• Decreased size and capacity of alveoli
• The respiratory rate is usually unchanged
• Decreased depth of respirations and oxygen intake
• Decreased ability to cough and expectorate sputum

Gastrointestinal System Changes

• GI system slows down causing inefficient absorbtion of nutrients
• Changes in the oral cavity, appetite is lost
• Delayed gastric emptying causes bloating and discomfort
• Changes in pH and decreased secretion causes malabsorbtion of B vitamins
• A decrease in Hepatic and renal reserves increase the difficulty to manage the medications and alcohol effects
• Affected Thirst regulation increases risk of dehydration

Physiological Gastrointestinal Changes

• Risk of drug toxicity
• Reduced elasticity of stomach wall
• Decreased bicarbonate production and gastromucosal protection
• Delayed gastric emptying
• Decreased secretion of pancreatic protease and lipase
• Peristalsis slows down
• Decline in rate of cell division and lining repair in the large intestine
• Changes in microbial fauna and Changes in DNA of epithelial cells
• Decreased need for calories due to a lowered basal metabolic rate
• Decreased appetite, thirst, and oral intake that may be a result of of altered G.I. function.
• Decreased lean body weight with an increased risk for malnutrition
• Decreased stomach emptying time
• Increased tendency toward constipation
• Increased susceptibility for dehydration
• Decreased chewing and swallowing with tooth loss

Endocrine System Physiological Changes

• Decreased secretion of hormones, with specific changes related to each hormone’s function.
• Decreased metabolic rate and decreased glucose tolerance, with resistance to insulin in peripheral tissues.
• Increased risk in glucose tolerance

Physiological Changes - Renal System

• Decreased kidney size, function, and ability to concentrate urine.
• Decreased glomerular filtration rate and decreased capacity of the bladder.
• Increased residual urine and impaired medication excretion.
• Impaired fluid balance, increased risk of dehydration/overload, increased risk of infection, possible incontinence, increased risk of drug toxicity.

Physiological Changes - Special Senses

• Possible hearing ability loss.
• Low-pitched tones are heard more easily.
• Inability to discern taste of food.
• Decreased sense of smell and changes in touch sensation.
• Decreased pain awareness.
• Older eyes show a Decreased visual acuity
• Older eyes Decreased accommodation with increased adjustment time to changes in light
• Older eyes present with Decreased peripheral vision and increased sensitivity to glare
• Common conditions of older eyes are: Presbyopia and cataract formation Causes structural changes in the inner ear affecting the ability to process speech and sound and nerve conduction. It also decreases blood flow to the ear.

Visual Problems

• AGE-RELATED MACULAR DEGENERATION (ARMD): A degenerative disorder of the macula affecting central vision (SCOTOMA) and visual acuity.

• MACULA: Situated in the posterior region of the retina, surrounding the fovea, dense with photoreceptor cells (cones for color, rods for black/white).

• Cataract: Opacities or yellowing of the lenses causing a cloud, that decreases the light coming to the retina

• Cataracts are a leading cause of blindness, and they are usually painless with a slow progression and can be unilateral/bilateral and are caused by UVL

• Glaucoma: damage in optic nerve for increased pressure causes Loss of vision. Intra Ocular Pressure is > 21 mmHg and has optic nerve potential for atrophy

• Retinopathy: is a Microvascular disease of both type 1 and type 2 DM that is damaged in microvascular system that impairs transport of O2 and nutrients to the eye

• Presbyopia: A gradual loss of eyes' ability to focus on nearby objects and is a normal part of aging

Special Senses Problems

• Auditory problem: Tinnitus and Cerumen of the ear cause hearing impairment

• Taste Problem: is Hypogeusia and xerostomia causes the loss a taste sense, poor dentition and a Olfactory dysfunction

Adverse reaction

• A sudden change in mental status is a common sign of an adverse reaction to a medication in the older client.

Pain - in older clients

• Description: is caused from degenerative changes in the musculoskeletal system and it will lead to functional limitations if the patient has failure to alleviate the pain
• Assessment: The patient that is restlessness, Verbally reporting pain, Agitation, Moaning and Crying
• Intervention: Monitor all signs and symptoms of pain and identify the the precipitating factor(s)
• Provide pain relief through measures: Distraction, relaxation, massage, and biofeedback and Administer pain medication as prescribed

Delirium

• Delirium with reduced ability to focus,sustain or shift attention and includes and Memory deficit, Disorientation, Language disturbance
• Development of a perceptual disturbance (Auditiory, Visual hallucinations)
• Delirium is Reversible if diagnosed early

Predisposing Factors of Delirium

• Age (over 75 years) and Dementia or baseline cognitive impairment Other predisposing factors include: Male sex, Depression, Functional dependence, Comorbidities or illness severity, Malnutrition, Visual and hearing impairments and Alcohol abuse

Precipitating Factors of Delirium

• Infections, Medications (polypharmacy, psychoactive drugs, sedatives), Iatrogenic events, Bladder catheter, Urea and electrolyte imbalance, Hospitalization,Low albumin level, Surgical procedures

Delirium Presentation

• presents Cognitive Symptoms (Inattention, Memory impairment, Disorientation) and Behavioral symptoms (Agitation or hypoactivity, Resistance to care, Sleep-wake disturbance) + Psychiatric Symptoms: Paranoia, hallucinations and Affective lability

Delirium - Differential Diagnosis

• Dementia with Behavioral Disturbance + Mood Disorders + Psychotic Disorder + Catatonia + Others

• Delirium is best managed by Maintain VS and I/O and Ensure good oxygenation while all nonessential medications are Stopped. Opioids are minimized. A full lab of workups is needed

Delirium - Behavioral Environmental Strategies that will help control

• Reorientation, calendars, clocks + A Room near nursing station + Lights on/off during day/night and Windows + Family, familiarity +Hearing aids and glasses Delirium is best dealt with by Pharmacological Therapy that is FDA unapproved such as Antipsychotics and Haloperidol Delirium and Dementia are separate conditions - the table at the end of the document outlines the clear differences