Geri Exam 2 PDF

Chapter 18: Sensory Function General senses  touch, pressure, pain, temperature, vibration, and proprioception (position sense)  Receptors located all over body  somatic o Provide sensory information about the body and the environment  Visceral  supply information about the int...

Chapter 18: Sensory Function General senses  touch, pressure, pain, temperature, vibration, and proprioception (position sense)  Receptors located all over body  somatic o Provide sensory information about the body and the environment  Visceral  supply information about the internal organs Specialized senses  produced highly by localized organs and specialized sensory cells  Sight, hearing, taste, smell, and balance Sensation  conscious or unconscious awareness of external and internal stimuli  Conscious  occurs via action potentials generated by receptors that reach the cerebral cortex Perception  interpretation of conscious sensations Vision  Visual acuity  ability to see clearly  important part of performing ADLs  Age-Related Changes o Eyelids lose tone and become lax  may result in ptosis of the eyelids, redundancy of the skin of the eyelids, and malposition of the eyelids o Eyebrows may turn gray and become coarser in men; outer thinning in both men and women o The conjunctiva thins and yellows in appearance  Membrane may become dry  diminished quantity and quality of tear production o Sclera may develop brown spots o Cornea yellows and develops a noticeable surrounding ring made up of fat deposits (arcus semilis) o Pupil decreases in size and loses some of its ability to constrict o Lens increases in density and rigidity  affecting ability to transmit and focus light o Peripheral vision decreases, night vision diminishes, and sensitivity to glare increase o Gradual reduction in the ability to see colors o Color deficits due to multiple disease processes  diabetes, glaucoma, macular degeneration, Alzheimer’s, and Parkinson’s o Ophthalmologic examination  blood vessels have narrowed and straightened; arteries seem opaque and gray; and drusen, localized areas or hyaline degeneration, may be noted as gray or yellow sports near the macula  Common Complaints o Floaters and Flashers  Floaters appear as dots, wiggly lines, or clouds that a person may see moving in the field of vision  more pronounced when looking at a plain background  occur more often after age 50, as tiny clumps of gel or cellular debris  caused by degeneration of the vitreous gel  more common in older adults who have undergone cataract operations or yttrium-aluminum-garnet (YAG) laser surgery  usually normal and harmless  if increase in number or changes in type, light flashes, or visual hallucinations are noted o may indicate a vitreous or retinal tear  detachment o visual hallucinations  brain tumor or cortical ischemia  Flashers occur when the vitreous fluid inside the eye rubs or pulls on the retina and produces the illusion of flashing lights or lightning streaks  Appear as jagged lines, last 10-20 minutes   Present in both eyes  spasm of blood vessels (migraine)  Warrant prompt medical attention  large in number, large number of new flashers appear, or partial loss of side vision is noted o Dry Eyes  Result as the quantity and quality of tear production diminish  Stinging, burning, or scratchy sensation  Episodes of excess tearing with discomfort, dryness, pain, redness, and possibly discharge in the eyes  Treatment  tear replacement or conservation  Tears may be replaced by instilling an OTC artificial tear preparation  Solid inserts that gradually release lubricants throughout the day  Ophthalmologist  temporarily close the lacrimal drainage system  Conservation  use of a humidifier when the heat is on, wraparound glasses to reduce evaporation of eye moisture caused by wind, and avoidance of smoke  Common Problems and Conditions o Presbyopia  Most common complaint of adults older than age 40  Diminished ability to focus clearly on objects  Lens loses its ability to focus on close objects  Accommodation is impaired  lens thickens and loses its elasticity  Ciliary muscles weaken the lens ability to contract  Treatment  wearing reading glasses or bifocals  Nursing  encourage patient to adjust to glasses and follow up with a visit to the ophthalmologist every 2 years o Health promotion/Illness prevention  Health promotion  Have a yearly eye exam and screening for eye disease and vision problems  Use a bright light when sewing, reading, and cooking; avoid fluorescent light  Have an UV-filter coating on spectacle lenses and sunglasses for outdoor activities  Prevention and treatment of disease  See your HCP/ophthalmologist with the occurrence of any pain, discharge, redness, swelling, or loss of vision  Take measures for detection and appropriate treatment of vision difficulties and eye disease  Maintain prescribed corrective lenses, low-vision aids, and medications o Blepharitis  Chronic inflammation of the eyelid margins  May be caused by seborrheic dermatitis or infection  Use of antihistamines, antidepressants, anticholinergics, and diuretics may exacerbate this condition  Deficiency of tear production  infection  Red, swollen eyelids; matting and crusting along the base of the eyelids at the margins; small ulcerations along the lid margins; and complaints of irritation, itching, burning, tearing, and photophobia  Treatment  aimed at removing the causative bacteria and healing the affected areas   Topical antibiotics or steroids  Pt must be taught scrupulous eye hygiene  good hand-washing habits  Mild soap  Proper cleaning and storage of contact lenses  Makeup products replaced every 3-6 months  Water resistant mascara, free of lash-extending fibers, and not applied to the base of the lashes  Eye-liner  medium-hard pencil, not applied to inner margin of eyelid  Avoid use of aerosol hairsprays o Glaucoma  Second leading cause of blindness in the US; first leading cause among African Americans  Can occur at any age  most at risk are adults older than 60  Group of diseases that can result in vision loss and lead to blindness due to damage to the optic nerve  Results from a blockage in the drainage of fluid in the anterior chamber of the eye  Chronic open-angle  Most common type  Develops slowly  Degenerative changes in the Schlemm canal obstruct the escape of aqueous humor  increased intraocular pressure (IOP)  May damage vision gradually and painlessly  patient is unaware of a problem until the optic nerve is badly damaged  Visual loss beings with deteriorating peripheral vision, intolerance to glare, loss of contrast perception, and difficulty adapting to the dark  Acute angle-closure  Occurs suddenly  complete blockage  Medical emergency!!  Symptoms o Severe eye pain o Redness in eye o Clouded or blurred vision o n/v o bradycardia o rainbow halos surrounding lights o pupil dilation o steamy appearance of cornea  Secondary glaucoma  Occurs due to complications from other medical conditions or certain drug therapies o Uncontrolled diabetes or HTN, cataracts, some types of eye tumors, uveitis or other irritation or inflammation o Steroid drugs  Serious eye injuries or surgical procedures may lead to onset  Nursing Management  Assessment  o May complain of dull eye pain or experience no early symptoms o Visual field testing reveals a loss of peripheral vision and increased IOP is seen on ophthalmologic examination o Difficulty seeing in low light or darker rooms and increase sensitivity to glare  Diagnosis o Need for patient teaching result from lack of exposure and inexperience regarding glaucoma causes and treatments o Pain resulting from increased IOP o Potential for infection resulting from eye drop instillation o Decreased ability to dress self resulting from visual impairment  Planning and expected outcomes o Patient will have no further loss of vision o Patient will follow prescribed glaucoma care guidelines daily o Patient will state eye pain is decreased o Patient will be free from eye infection o Patient will be able to perform ADLs safely and independently  Intervention o Teach patient that glaucoma is a chronic condition requiring lifelong medical treatment o Follow care guidelines o If medication fails to control rising IOP  surgical intervention  Trabeculoplasty  outpatient  Requires IOP check 3-4 hours after  4-8 weeks to see if procedure as effective  Sudden rise in IOP may occur after  Trabeculectomy  overnight hospitalization  Routine post anesthesia care  Protection of the operated eye with an eye patch or a shield, proper positioning of the patient on the back or on the side of the non operated eye, and the use of a call light and side rails  Administration of pain medications and cold eye compresses to maintain comfort  Monitoring for increased IOP, bleeding, or infection  Assistance and teaching or safe, independent performance of ADLs  Evaluation o Documentation of achievement of the expected outcomes, no further vision loss, and the independent performance of ADLs o Pt must be able to state name and dosage of the prescribed eye medications and describe their daily use o Identify significant signs and symptoms o Cataracts  Most common disorder found in the aging adult  40s and 50s  No significant effect on vision  Risk factors  smoking, prolonged exposure to UV light, and diabetes  Changes in the lens leads to cataracts  Protein meant to keep the lens clear and allow light to pass through starts to clump together behind the lens  Creates a cloud in a small area of the lens  As the cataract grows, vision becomes more difficult  reduced sharpness of images reaching the retina  Lens becomes discolored over time with yellow/brown tint  Secondary cataract  related to other health problems  Traumatic cataract  may develop after an eye injury  Radiation cataract  radiation exposure  Size and location determine the amount of interference with clear sight  Located near the center of the lens produces more noticeable symptoms o Dimmed, blurred, or musty vision o The need for brighter light to read o Glare and light sensitivity o Halo that appears around lights o Double vision or multiple images in one eye o Loss of color perception o Recurrent eyeglass prescription changes  Develop slowly and at different rates in each eye  Nursing Management  Assessment o Trouble reading and necessity for constantly changing one’s glasses o Lens opacity may be visible on external or internal eye exam  Diagnosis o Anxiety resulting from uncertain surgical outcome o Need for patient teaching about cataracts resulting from lack of exposure o Potential for injury resulting from changes in visual acuity o Decreased ability to dress self resulting from inability to see the body and face clearly enough to maintain appearance of clothes and cosmetics  Planning and expected outcomes o Patient will have cataract surgery when recommended o Patient will ask questions about preoperative and postoperative care and report satisfaction with information o Patient’s affected eye with bee free from increased IOP, stress on the suture line, hemorrhaging, and infection o Patient will verbalize appropriate home care activities to avoid and activities to do after surgery o Patient will demonstrate correct administration of eye drops o Patient will remain injury-free by maintaining a safe environment to avoid falls or bumping into items  o Patient will use caution when driving before and after surgery  Intervention o Preoperative and postoperative surgical care  surgery is only method for treating cataracts o Preoperative  administering eye drops and a sedative o Postoperative  teaching patient and family home care procedures o Home care instructions  special precautions o If lens implant has not been inserted  pts need to wear contact lenses or cataract glasses o Cataract glasses  loss of depth perception and distorted peripheral and color vision  Objects are magnified 25% and appear larger and closer than they really are  Home care after cataract surgery o What to expect  The affected eye may be bruised or bloodshot for up to 7 days  May experience itching or mild discomfort for several days  May experience some fluid discharge  Sensitivity to light  Eye may have a scratchy or sand like feeling for up to 2 weeks  May feel tired for the first 24 hours o Activity level and care  No driving for 2 days  Avoid bending at waist or heavy lifting for 2 days  Avoid alcohol for at least 2-4 hours  Do not rub or press on eye  Sleep on back or nonoperative side for 2 days  Wear the bandage or eye pad  Perform regular hand hygiene before attending to any bandage or eye pad  Monitor pain and report if unrelieved by medication  Instill eye drops using a clean technique  Recognize signs and symptoms of infection and report ASAP  Follow up with provider  Evaluation o Documentation of achievement of the expected outcomes o Pt and family with arrange for assistance with ADLs for the first 24-48 hours after surgery o Retinal disorders  Age-related MD  Leading cause of blindness in people over 50  Does not cause total blindness but results in loss of central vision  Causes damaged to the macula leading to changes in the center of the field of vision   Peripheral vision is unchanged  The cells within the macula diminish in functional ability with age, and replacement of the damaged cells is decreased, causing irreversible damage to the macula  Central visual acuity declines  Types of AMD o Dry macular degeneration  involutional macular degeneration  Caused by breakdown or thinning or macular tissue resulting from the aging process  Vision loss is gradual o Wet macular degeneration  exudative macular degeneration  Results when abnormal blood vessels form and hemorrhage on the retina  Vision loss may be rapid and severe  More common among Caucasians  Increased risk in those with family history  Smoking  doubles the risk  Symptoms o Difficulty performing tasks that require close central vision o Decreased color vision o Dark or empty area in the center of vision o Straight lines appearing wavy or crooked o Words on a page looking blurred  Diabetic retinopathy  Loss of visual function  most common complications of diabetes  Altered circulation  retinal edema, degeneration, or detachment  Affects the retinal capillary circulation  Ballooning of these tiny vessels  hemorrhaging, scarring, and blindness  Vascular changes in and around the retina  macular edema  retina swells  No symptoms of early retinal changes exist  No symptoms may be apparent even when the retinopathy is advanced  HTN retinopathy  Caused by uncontrolled HTN  Chronic HTN will cause progressive damage to the retina with few or even no symptoms until the late advancement of symptoms  Permanent arterial narrowing, arteriosclerosis, and vascular wall hyperplasia  Retinal detachment  Occurs when the sensory layer of the retina separates from the pigmented layer   Tears or holes occur in the retina  trauma, aging, hemorrhaging, or tumor o When a tear occurs  fluid seeps between the layers  detachment  Symptoms o Light flashes o A shower of floaters the resemble spots, bugs, or spider webs o Loss of vision o Veil or curtain obstructing vision  Nursing Management  Assessment o Unable to thread a needle or that the words on a page look blurred o Retinal detachment  flashes of light followed by floating sports before the eye with progressive loss of vision o Monitoring the patient’s subjective statements about changes in vision and observing for signs or anxiety  Diagnosis o Need for patient teaching resulting from lack of exposure to accurate information about the effect of diabetes on the eyes o Need for patient teaching resulting from retinal detachment condition, surgery, preoperative and postoperative care, and home care after surgery o Anxiety resulting from fear of blindness  Planning and expected outcomes o Pt will adjust successfully to vision loss by using low- vision aids o Pt will state in his or her own words the effect of diabetes on the eyes o Pt will see and ophthalmologist yearly o Pt will ask questions about preoperative and postoperative retinal surgery care and report satisfaction with the information o Pt’s affected eye will be free from further retinal detachment, infection, or hemorrhaging o Pt will verbalize appropriate home care activities to participate in after retinal surgery o Pt will demonstrate correct administration of eye drops o Pt will report reduced anxiety  Intervention o Pt must learn to cope with chronic, gradual vision loss o Self-monitor their central vision with an Amsler chart o How to obtain and use low-vision aids o Teaching about the condition and yearly follow-up visits with ophthalmologist o Postoperative care  administration of eye medication, pain medication, antiemetics, and cough medication o Avoid jerking movements of the head o Home care instructions  Report increases in floaters or flashes of light, decreased vision, drainage, or increased pain   Administer eye drops  Limit physical activity for 1-2weeks, and resume active sports and heavy lifting as indicated by a physician  Make follow-up appointments with the ophthalmologist  Evaluation o Describe condition and report use of low-vision aids o Surgery for retinal detachment  experience no complications and gradual improvement in vision o Report reduced anxiety LOW-VISION AIDS Magnifying devices: glasses, stand or hand magnifier, telescope, video magnifier. Some have built-in lighting Audio books or electronic books apps for smart phones, computers, and tablets devices with speech capability: watches, timers, blood glucose monitors, BP cuffs, prescription bottles Large print reading material and items with large-sized numbers/letters and high-contrast colors Increased light: higher-watt light bulbs and number of lights indoor, adjust light to reduce glare inside and wear sunglasses or wide brimmed hat outdoors, use color to create contrast, use a bold felt tip marker to make lists or notes Request a referral early to access the many low-vision aids and devices to help with daily activities. Many people will need vision rehabilitation to achieve the best possible quality of life o Visual impairment  Most common sensory problem  Low vision  20/50 to 20/200  Legally blind  visual acuity of 20/200 or worse in the better eye with the aid of the best possible correction with the use of spectacles or contact lens  Blindness results from diabetic retinopathy, glaucoma, cataracts, and MD  Sudden vision loss = medical emergency  May be caused by retinal detachment or eye injury  Nursing Management  Assessment o Requires an understanding of the patient’s response to the vision loss o Loss of vision may result in a self-esteem disturbance  social isolation  Decreased self confidence, which may affect interactions with others; Ability to carry out normal daily activities; Job performance; Desire to engage in familiar hobbies o Ability to cope depends on the type, amount, and duration of the vision loss as well as the patient’s support system and coping style o Over time  can compensate by increasing sensitivity in other senses  Diagnosis o Decreased self-esteem resulting from sudden loss of vision  Social disengagement resulting from impaired o communication o Inadequate coping resulting form sudden loss of vision o Decreased ability to feed/bathe/toilet self resulting from visual impairment o Decreased mobility resulting from visual impairment o Potential for injury resulting from impaired vision  Planning and expected outcomes o Pt will receive himself or herself positively, by making positive statements about self o Pt will participate successfully in activities with others o Pt will demonstrate increased objectivity and ability to solve problems, make decisions, and communicate needs o Pt will safely provide self-care by using low-vision aids and environmental strategies o Pt will demonstrate the safe and correct use of adaptive devices  Intervention o Counseling o Problem solving o Rely heavily on various techniques and methods when communicating with the patient o Organizing the environment; encouraging the use of the clock method of eating; using a sighted guide to assist in ambulation o Coding schemes o Referral to a social worker o Mobility training, vocational rehabilitation, self-care skills training, special education, and financial assistance o Low-vision aids  Evaluation o Pts who display signs and symptoms of depression or social isolation require further counseling to talk about their feelings, strengths, and resources Signs and behaviors that may indicate vision problems Patient may report Pain in eyes Difficulty seeing in darkened area Double or distorted vision Sudden loss of vision or blurred vision Flashes of light Halos surrounding lights Others may notice the patient Getting lost Bumping into objects Straining to read or not reading Spilling food on clothing Withdrawing socially Making less eye contact Displaying placid facial expressions Viewing the tv at a close range Suffering from a decreased sense of balance Mismatching clothes Hearing and Balance  External ear, middle ear, and inner ear  External and middle ear  involved only in hearing  Inner ear  both hearing and balance  External ear  consists of the auricle and the external auditory canal  Middle ear  air-filled space that contains the tympanic membrane, the eardrum, and the auditory ossicles  Inner ear  contains the sensory organs for hearing and balance o Made up of interconnecting, fluid-filled tunnels and chambers in the petrous portion of the temporal bone  Organs of balance o Vestibule  contains the membranous labyrinth, which consists of the utricle and saccule  Evaluates the position of the head relative to gravity or linear acceleration and deceleration o Semicircular canals  kinetic labyrinth  Evaluates the movements of the head  Age-Related Changes o May be seen in the auricle  appears larger because of continued cartilage formation and loss of skin elasticity o Lobule of the auricle becomes elongated, with a wrinkled appearance o The periphery of the auricle becomes covered with coarse, wirelike hairs o Men have larger tragi o Tragi become larger and coarser with age o Auditory canal narrows o Hairs lining in the canal become coarser and stiffer o Cerumen glands atrophy o Dull, retracted, and gray appearance  tympanic membrane o Decreased vestibular sensitivity o Balance decline  combination of decreased sensory input, slowing of motor responses, and musculoskeletal limitations o Increase in postural sway  Common problems and conditions o Pruritus  Itching within the external auditory canal results from age-related atrophic changes in the skin  Atrophy of the epithelium and epidermal sebaceous glands  dryness  Itch-scratch-itch cycle initiated by dry skin  May be exacerbated by efforts to retard and remove dry earwax buildup  Several drops of glycerin or mineral oil instilled in the ear canal daily  add moisture to the external ear  Steroid-containing medications  resistant conditions o Cerumen impaction  Reversible, often overlooked, cause of conductive hearing loss  Atrophic changes in the sebaceous and apocrine glands lead to drier cerumen  These changes, narrowed auditory canal, and stiffer, coarser hairs lining the canal  cerumen impaction  Cerumen blockage may interfere with passage of sound vibrations through the external auditory canal to the middle and inner ear, affecting a person’s ability to hear and communicate   social isolation and depression   Common symptoms  Hearing loss, a feeling of fullness in the ear, itching, and tinnitus  Identification and removal of the impaction may restore hearing acuity and relieve symptoms  Older adults have a decreased production of cerumen that is a drier consistency creating more risk of impaction  Nursing Management  Assessment o Ear fullness, itching, difficulty hearing o Otoscopic examination  will show whether the external ear canal is obstructed by cerumen and whether the tympanic membrane is visible  Diagnosis o Social disengagement resulting from difficulty communicating with family and friends  Planning and expected outcomes o Pt will be free from cerumen impaction o Pt will follow proper instillation of softening agents o Pt will report satisfactory level of involvement with family and friends  Intervention o Assess patient for signs of hearing impairment that may indicate cerumen impaction  difficulty understanding the spoken word, loud radio and tv volume, withdrawal from social activities and accompanying depression, and possible confusion and paranoia o Follow protocol for cerumen removal o Management of cerumen impaction  Verify any history of ruptured tympanic membrane, tympanostomy tubes, or any recent ear surgery  Impaction may be resolved by instillation of fluid into the ear canal  OTC cerumenolytic agent, baby oil, mineral oil, liquid docusate sodium, hydrogen peroxide  Water to normal saline that has been warmed to body temperature may be used to irrigate using an ear syringe  Cerumen spoon or curette  liquid is contraindicated or does not resolve the problem o Tinnitus  Chronic combination of both conductive and sensorineural hearing loss  Subjective sensation of noise in the ear, defined as ringing, buzzing, or hissing  Occurs more frequently in whites  12.3% men; 14% women  Common causes  Noise or toxin damage to the hair receptors of the cochlear nerve and age-related changes in the organs of hearing and balance  Not a disease, but a symptom  Subjective  audible only to patient  Ringing, buzzing, humming  Objective  rare  audible to both patient and examiner  Low pitched   Associated with an identifiable cause  muscle spasms or vascular and musculoskeletal cranial disorders  Unilateral  associated with more serious diseases  Meniere disease, tumors, vascular problems  Bilateral  Nursing Management  Assessment o Tinnitus screener  assess patient for the presence and level of tinnitus o Pt should answer questions about the effect of the tinnitus on daily living o Tinnitus and Hearing Survey  can identify effect of tinnitus, hearing loss, and sound tolerance  Diagnosis o Inadequate health maintenance resulting from a lack of knowledge about tinnitus prevention practices o Anxiety resulting from coping with chronic condition of ringing in the ears  Prevention and expected outcomes o Pt will follow tinnitus prevention practices o Pt will use home masking measures and a hearing aid or tinnitus masker to relieve tinnitus o Pt will cope with anxiety independently by using relaxation techniques  Intervention o Prevention practices  Treating correctable problems that cause tinnitus  Softening loud sounds through improved acoustics  Using protective ear plugs  Avoiding foods, drinks, and drugs that contain ototoxic substances  Home masking measures  Portable radio tuned between stations  Loud ticking clock  Soft, pleasant music  Electric fans  Sleeping with head elevated on two pillows  Coping strategies  relaxation training, biofeedback, counseling  Evaluation o Tinnitus Handicap Inventory (1996)  to identify the problems that individuals have with tinnitus Chronic Tinnitus Interventions Mild Tinnitus (does not affect ADLs) Reassure the older adult that tinnitus is not life-threatening Instruct the pt to avoid ototoxic substances in food, drinks, and drugs  Avoid quinine, aspirin, and anti- inflammatory drug compounds  Avoid caffeine, sodium, chocolate, tea, and alcohol Moderate Tinnitus (interferes with Teach simple home masking measures sleep and ADLs) Recommend evaluation for properly fitted  hearing aid More sophisticated, commercial tinnitus markers and instruments may be matched to the individual’s pitch of one’s tinnitus Use habituation therapy Medications may be used, but with caution because they may cause drowsiness and mental confusion Severe Tinnitus Refer patient for extensive counseling and education Apply all moderate tinnitus interventions Teach relaxation methods to cope with stress and promote sleep; combined with biofeedback, this has proved to be beneficial for long-term sufferers Perform electrical stimulation Perform acupuncture Perform surgery Contact local self-help tinnitus support groups o Hearing loss  17%  Not a normal part of the aging process  More than 30% of adults age 65 and older have some type of hearing impairment  Hearing impairment  conductive, sensorineural, or mixed  Conductive  results from interruption of the transmission of sound through the external auditory canal and middle ear  Cerumen impaction, otitis media, and otosclerosis  Sensorineural  results when the inner ear, auditory nerve, brainstem, or cortical auditory pathways do not function properly so that sound waves are not interpreted correctly  Cochlear implants  Mixed  a conductive hearing loss superimposed on sensorineural hearing loss o Presbycusis  A sensorineural hearing loss  Most common form  Bilateral  resulting in difficulty hearing high-pitched tones and conversation speech  Affects men more than women  Cause remains unclear  Signs and symptoms  Increasing the volume on the tv or radio  Tilting the head toward the person speaking  Cupping the hand around one ear  Watching the speaker’s lips  Speaking loudly  Not responding when spoken to  Nursing Management  Assessment o Subjective data should be obtained  onset, type, and progression of hearing loss, including differences in either ear; family history of hearing loss; presence of  other symptoms such as pressure or pain in the ears, ringing in the ears, or dizziness; history of head injury or noise exposure; and current medications o Objectively  behavioral symptoms of hearing loss o Complete hearing evaluation  Diagnosis o Social disengagement resulting from difficulty with communication o Potential for chronic low self-esteem resulting from hearing loss  Planning and expected outcomes o Pt will effectively use aural rehabilitative techniques o Pt will maintain satisfactory social contacts and activities with others o Pt will perceive himself or herself positively, as evidenced by positive self-talk and behaviors  Intervention o Aural rehabilitation and facilitation of communication o Pts often deny their hearing loss and need more encouragement and support to explore the various methods to improve hearing o Aural rehab  auditory training, speech and reading training, hearing aids o Basics of hearing aid use and care  Assistive-Listening Devices  Hearing loop systems  Frequency-modulated systems  Infrared systems  Personal amplifiers o Dizziness and disequilibrium  Common complaints  5 age-related conditions of disequilibrium  Benign paroxysmal positional vertigo  severe episodes of vertigo precipitated by a particular change in head position  Ampullary disequilibrium  vertigo or disequilibrium associated with rotational head movements  Macular disequilibrium  vertigo precipitated by change of head position in relation to the direction of gravitational force  Vestibular ataxia of aging  a feeling of unbalance when ambulating  Meniere’s disease  an uncommon disease seen most often in older women, characterized by severe vertigo accompanied and usually preceded by tinnitus and progressive low-frequency sensorineural hearing loss  Causes  Visual disturbances  Musculoskeletal disorders  Neurologic dysfunctions  Metabolic abnormalities  Cardiovascular disease  Medications  Signs and symptoms  Whirling dizziness when head is moved in a certain position   Dizziness or imbalance when the head is moved quickly to the right, left, up, or down  Constant feeling of imbalance when walking o Health promotion/illness prevention  The ear  Health promotion o Notify physician of any pain, discharge, redness, swelling, dizziness, ringing in ears, or loss of hearing o See physician for early detection and appropriate treatment of hearing difficulties and ear disease o Maintain prescribed hearing aids, ALDs, and medications  Prevention of disease o Have a periodic ear exam and screening o Avoid exposure to hazardous noise o Use protective earplugs in high-risk occupations and activities o Meniere disease  Caused by pressure within the labyrinth of the inner ear  excessive endolymphatic fluid that causes swelling in the cochlea  Vertigo, tinnitus, and hearing loss  Loss of balance, n/v, and spasmodic eye movements  615,000 people  45,5000 newly diagnoses each year o Nursing Management of vertigo  Assessment  Description of vertigo episodes; a list of accompanying symptom; a history of balance problems; drug history  Complete assessment of hearing and balance  Diagnosis  Potential for injury resulting from acute onset of vertigo  Need for pt teaching resulting from lack of exposure and inexperience about cause of vertigo and its treatment  Need for pt teaching resulting from lack of exposure to preoperative and postoperative surgical care for Meniere’s disease  Anxiety resulting from uncertainty of future vertigo attacks  Planning and expected outcomes  Pt will accurately follow the prescribed medication regimen and exercise protocol  Pt will safely follow measures to reduce dizziness and prevent falls  Pt will state the causes and treatment of vertigo  Pt will ask questions about the surgical care for Meniere disease  Pt will meet his or her own self-care needs, as evidenced by reports of normal appetite, sleep, and activity  Intervention  Antivertiginious drugs  Vestibular rehabilitation therapy  Surgery o Preoperative  giving instructions for postoperative care and sedating the pt o Postoperative  positioning the operative ear up for 4 hours after; medicating for pain and vertigo; following safety precautions; monitoring the pt for changes in hearing, vertigo, neurologic symptoms, or facial  paralysis; instructing the pt to keep his of her mouth open when sneezing or coughing  No complete cure  Measures to reduce dizziness o Move slowly o Avoid bright, glaring lights o If occurring during ambulation, lie down immediately and hold the head still Taste and Smell  Senses of smell and taste diminish with aging  Decreased sensitivity to odors  potential risk for noxious chemicals and poisonings  Age-Related Changes o Result from alterations in the oral mucosa and tongue, and the pathological state of the nasal cavity o In health older adults, olfactory losses result from normal aging, medications, viral infections, long-term exposure to toxic fumes, and head trauma o Dramatic decline in sensitivity to airborne chemical stimuli o Recognition of odors declines o Taste loss results from disease states of the nervous and endocrine systems, nutritional and upper respiratory conditions, viral infections, and medications o Xerostomia  most common cause of change in taste  Common Problems and Conditions o Xerostomia  Dry mouth  Subjective sensation of abnormal oral dryness  Reduced salivary flow  Disease states and medications  May lead to increased risk of serious respiratory infection, impaired nutritional status, and reduced ability to communicate  c/o abnormal taste sensations, burning of the oral tissues and tongue and cracking of the lips  Oral mucosa is dry, thin, and smooth, and the tongue may have a thick, white, foul-smelling coating  Decrease in salivary flow interferes with chewing and swallowing  Dentures  sore gums and tissues  denture slippage from loss of salivary flow  Nursing Management  Assessment o Health history of factors leading to disease in salivary flow and pt’s oral complaints o Assessment of the lips  red, inflamed, cracked, and dry lips, may bleed o Mucous membranes  dry, red, edematous o Tongue  red areas and a coated base  thicker, with prominent lingual groove and papillae o Saliva  scant, ropy, viscid o Pt’s voice may be dry and raspy  Diagnosis o Inadequate oral mucous membrane resulting from changes induced by xerostomia o inadequate nutrition resulting from changes induced by xerostomia  Planning and expected outcomes o Pt will verbalize an increase in taste sensation  o Pt will exhibit unimpaired oral mucosa tissue integrity, as evidenced by moist, pink, smooth mucosal surfaces o Pt will verbalize no oral discomfort o Pt will state contributing factors, symptoms, and treatment of xerostomia o Pt will demonstrate a correct oral hygiene regimen  Intervention o Attaining intact oral mucosa tissue integrity o Teaching pts about the factors leading to a decrease in salivary flow, as well as the associated symptoms o Oral hygiene  brush twice daily with a soft bristled toothbrush and a nonabrasive fluoride toothpaste, daily flossing o 2-3 L of fluid per day o Use of artificial saliva, sugar-free hard candy, and gum Touch  Involves tactile information on pressure, vibration, and temperature  Touch sensation usually results from stimulation of receptors in the skin or in tissues immediately beneath the skin  Pressure sensation generally results from deformation of deeper tissues  Vibration sensation results from rapidly repetitive sensory signals  Sensitivity to light diminishes  decreased density of cutaneous receptors for touch sensation  Tactile vibratory thresholds progressively increase with age  Warm-cold difference threshold increases  Most common disorders affecting tactile information o CVA, PVD, and diabetic neuropathy  Signs and symptoms of CVA depend on the cerebral artery affected and the portion of the brain supplied by that artery  In PVD and diabetic neuropathy  impaired blood flow manifests as a loss of sensation  Intervention o Preventing accidental trauma and injury o Pt education on skin, leg, and foot care Chapter 19: Cardiovascular Function Heart disease is the leading cause of death and major cause of disability  CHD is the principle type  Risk factors for CVD  elevated cholesterol, HTN, diabetes, tobacco use, physical inactivity, obesity, alcohol use, advancing age, and heredity  Atherosclerosis  underlying cause of most clinical cardiovascular problems, is typically present for years before the onset of a clinical event such as a heart attack, or symptoms such as angina manifest Age-Related Changes  Heart rate decreases, the left ventricular wall thickens and results in an overall increase in oxygen demand  Increase in collagen and decreased in elastin in the heart muscle and vessel walls  Size of the left atrium increase, and aortic distensibility and vascular tone decrease  Decrease myocardial muscle contraction  decreased cardiac output and cardiac reserve  Decreases in diastolic pressure, diastolic filling, and beta-adrenergic stimulation  Increase in atrial pressure, systolic pressure, wave velocity, and left ventricular end diastolic pressure   Muscle contraction, muscle relaxation, and ventricle relaxation phases are elongated  S4 heart sound  Grade 1 or 2 systolic murmur (50%)  Conduction System o SA node, AV node, and bundle of His become fibrotic o Number of pacemakers in the SA node decreases  less responsiveness of the cells to adrenergic stimulation o ECG  notched P wave, prolonged P-R interval, decreased amplitude of the QRS complex, a notched or slurred T wave  Vessels o Calcification of the vessels occurs, making them tortuous o Elastin in the vessel wall decreases  thickening and rigidity  Increases risk of atherosclerotic buildup o SBP is increased because of loss of atrial elasticity o DBP remains the same or may be elevated slightly  pulse pressure widens o Less sensitive to baroreceptor regulation of BP  Fluctuations in BP and contributes to increased SBP o Isolated HTN (ISH)  Response to stress and exercise o Reduced stress response + changes to the heart and vessels affect the body’s reaction to exercise o Decreased CO and cardiac reserve  diminish response to stress o Heart rate increases more slowly  Once elevated, takes longer to return to the resting rate Common Cardiovascular Problems  CVD is leading cause of death o Strokes, HTN, heart failure, arrhythmias, valvular conditions, PVD  Risk Factors o Nonmodifiable  Male gender  Age (men>45, women>55)  Heredity  Family hx of premature CVD o Modifiable  Cigarette smoking/tobacco use  HTN or on an antihypertensive drug  Physical inactivity  Overweight/obesity  Diabetes mellitus  Atherogenic diet (high intake of saturated fats and cholesterol)  Dyslipidemia o Diet  Total cholesterol level of 150 mg/dL is when atherosclerosis begins to accelerate  Women have a higher prevalence of hypercholesterolemia than men  LDL should be 100 mg/dL  removes LDL from arterial walls and back to liver  Decreasing fat content in diet is key to lowering TC levels o Smoking  Increases platelet aggregation  Nicotine increases BP and cardiac demand  Increases individual’s risk for stroke   More likely to develop CVD than nonsmokers  Carbon monoxide in tobacco smoke decreases the oxygen- carrying capacity of the blood o Physical activity  Moderate to vigorous aerobic activity for a total of 75-150 minutes per week  Moderate- to high-intensity muscle strengthening activity at least 2 days per week  10-15 minute warmup o Obesity  Healthy BMI = 18.5-25 kg/m  Overweight = 25-29.9 kg/m  Obese = 30 kg/m or greater  37% of adults >60years were obese  Excess body weight increases CV risk factors (increased LDL, BP, blood glucose, and reduces HDL) o Diabetes  Individuals with diabetes mellitus are 2-4x more likely to die of cardiovascular causes  Silent MI (asymptomatic)  more common in individuals with DM and in older adults o Stress  Excessive stress is linked to CHD  Can trigger asthma  HTN and IBS o Menopause  Estrogen is believed to help maintain adequate levels of HDL and relaxing the smooth muscles of arteries  Lost after menopause  HTN o Most common preventable cause of disease and death o Known as silent killer o 80% of older adults will have HTN by year 2060 o Contributes to CVD, HF, and end organ damage o Diagnosed by three different measures on more than 2 office visits Category Systolic BP And/or Diastolic BP Normal