NCM 114 LECTURE: Nursing Care of the Older Adult in Chronic Illness PDF

NCM 114 LECTURE: Nursing Care of the Older Adult in Chronic Illness Bachelor of Science in Nursing - Year 3 Professor: Caesar G. Balatero, RN, MN, USRN, SGRN NURSING CARE OF THE OLDER ADULT IN CHRONIC Risk factors:...

NCM 114 LECTURE: Nursing Care of the Older Adult in Chronic Illness Bachelor of Science in Nursing - Year 3 Professor: Caesar G. Balatero, RN, MN, USRN, SGRN NURSING CARE OF THE OLDER ADULT IN CHRONIC Risk factors: ILLNESS o Increased age - Good sensory function is an extremely valuable asset that o Smoking and alcohol is often taken for granted. For instance, people are better o Diabetes, hyperlipidemia able to protect themselves from harm when they can see, o Trauma to the eye hear, smell, touch, and communicate. o Exposure to the sun and UVB rays - The reduced ability to protect oneself from hazards o Corticosteroid medications because of sensory deficits can result in serious falls from Symptoms unseen obstacle, missed alarms and warnings, ingestion o Blurred vision of hazards because of sensory deficits can result to o Glare serious falls from unseen obstacle, missed alarms and o Halos around objects warnings, ingestion of hazardous substances form not o Double vision recognizing bad tastes, an inability to detect the odor of o Lack of color contrast or faded colors smoke or gas, and burns and skin breakdown because of o Poor night vision decrease cutaneous sensation of excessive temperature - Surgery and pressure. Phacoemulsification o “small incision cataract surgery” Sensory Impairment o small incision done outside the cornea Visual Impairment o a tiny probe is inserted which emits ultrasound - Personal cost for older person with visual impairment waves that soften & break up the lens so that it Loss of independence can be removed by suction Social isolation Extracapsular / Intracapsular cataract surgery Depression o incision is longer on the side of cornea & removes Decreased quality of life the cloudy core on the lens in one piece - Signs of difficulty with vision o the rest of the lens is removed by suction Squinting or tilting head to see - Glaucoma Changes in ability to drive, read, watch television, or Increase in intraocular pressure (IOP) → optic nerve write damage → vision loss Holding objects closer to the face Difficulty with color discrimination and walking up or Open angle down stairs o Slowed flow of aqueous humor through Hesitation in reaching for objects trabecular meshwork → build up→ increased IOP Not being able to find something (American Society on → damage to renal nerve fiber → loss of vision Aging, 2003) o Painless vision loss – Midperipheral visual field - Cataract loss Opacity of the crystalline lens or its capsule (partial or Angle-closure complete) o Angle of the iris obstructs drainage of aqueous Causes humor through trabecular meshwork → increased o injury -- traumatic o exposure to heat, UV light IOP → visual changes o heredity / congenital Symptoms o aging (>55) – senile o Unilateral headache o DM – secondary o Visual blurring o smoking & alcoholism o Nausea and vomiting Lens clouding → decreased light to retina → limited o Photophobia vision Risk Factors for Glaucoma Development is slow and painless o Increased intraocular pressure Leading cause of blindness in the world o Older than 60 years of age o Family history of glaucoma > 50% of adults > 65 years have cataracts → visual o Personal history of myopia, diabetes, problems hypertension, or migraines o African American ancestry 1 of 6  CARE OF OLDER ADULTS: NURSING CARE OF THE OLDER ADULT IN CHRONIC ILLNESS Nursing Care - Nursing Diagnoses for Vision- Impaired Older Patients o Explain the importance of continued use of eye Evaluate functional ability medications as ordered to prevent further visual o Perform activities of daily living, including the loss ability to read medication labels o Explain the need for continued medical o Drive or take public transportation supervision for observation of IOP to ensure o Ambulate safely in familiar and strange control of the disorder environments o Teach client to avoid exertion, stooping, straining o Shop and pay for food and personal items for a bowel movement, coughing, heavy lifting, or o Prepare food while maintaining a safe and wearing constricting clothing, since these hygienic environment increase IOP o Engage in recreational and leisure activities o Instruct the client to report severe eye or brow - Nursing Diagnoses for Vision- Impaired Older Patients pain & nausea to the physician Sensory/perceptual alterations: visual - Eye Examination: Visual Acuity Encompasses a variety of nursing goals and always start with the right eye to ensure accurate interventions communication recording o Safety cover the eye not being tested with an occluder o Mobility 20/20 at 6 y/o o Self-care activities Numerator (20 ft, the distance the person stands from o Mood assessment the chart) Hearing loss Denominator (distance from which the normal eye - > 30% aged 65 to 76 years can read the chart) - 50% >75 years CF, HP, LP, NLP - Older men > older women - Age-Related Macular Degeneration (ARMD) - Caucasian men and women > African American men and Dry (atrophic form)-involutional mac deg women o Breakdown or thinning of macular tissue related - Temporary threshold shift (TTS) to the aging process Sounds < 75 dB(A) → temporary hearing loss o Atrophy Sounds > 85 dB(A) for 8hrs/day + many years → o Retinal pigment degeneration permanent loss o Drusen accumulations - Risk Factors o Other symptoms Long-term exposure to excessive noise o Slow progression of visual loss Impacted cerumen (ear wax) Wet (Neovascular exudates) - exudative macular degeneration Ototoxic medications o Blood or serum lead from newly formed blood Tumors Diseases that affect sensorineural hearing vessels beneath retina→ scar formation + visual Smoking problems History of middle ear infection o Other symptoms Chemical exposure (e.g., long duration of exposure to - More light required for reading trichloroethylene) - Blurred vision 1) Conductive Hearing Loss - Central scotomas - Metamorphopsia - Sound unable to be transmitted → poor reception + Other symptoms of Macular D amplification o Difficulty performing tasks – close central vision – - Site of problem: External or middle ear reading and sewing - Cause o Decreased color vision Otitis externa o Dark or empty area in the center of vision Impacted cerumen o Straight lines appearing wavy and crooked - Most common and reversible o Words on a page looks blurred Otitis media Risk Factors for ARMD Benign tumors o Age (above the age of 50) Tympanic membrane perforation o Cigarette smoking Foreign bodies o Family history of ARMD Otosclerosis o Increased exposure to ultraviolet light - Conductive Hearing Loss o Caucasian race and light colored eyes Transmission hearing loss o Hypertension or cardiovascular disease Damage external or middle ear o Lack of dietary intake of antioxidants and zinc 2 of 6  CARE OF OLDER ADULTS: NURSING CARE OF THE OLDER ADULT IN CHRONIC ILLNESS Failure of sound waves to be transmitted through Nursing Diagnoses Associated with Hearing Impairment the external and/or middle ear Assessment - Causes - Ability to perform activities of daily living Impacted earwax Communication perforated eardrum Driving or taking public transportation otosclerosis (decreased mobility of the ossicles) Safety awareness including the ability to hear alarms, - Treatment: hearing aids that amplify the sound, since doorbells the inner ear and organs of sound perception are not Engaging in leisure and recreational activities damaged. Diagnosis 2) Sensorineural Hearing Loss - Sensory/perceptual alterations: hearing with a variety of - Problems with cochlea + auditory nerve → sound nursing goals and interventions distortion Communication - Causes Safety Presbycusis Self-care activities (bilateral progressive hearing loss especially at Mood high frequencies in elderly people) Recreation and leisure activities High-frequency hearing loss from excessive noise (industrial noise, gunfire, “rock & roll” deafness) Protocol in cerumen removal Impaired ability to hear high pitches Clip and remove ear hairs Rare, severe hearing loss or deafness Instill softening agent, mineral oil, carbamide peroxide or Damage as a result of excessive noise exposure glycerin solution Meniere’s disease Irrigate the ear using bulb syringe Tumors Use a solution of 3oz 3% hydrogen peroxide in 1 qt water Infection warmed to 98 to 100 F., or plain normal saline solution - Perceptive / “Nerve” hearing loss Place a towel around the client’s neck and tip head to the - Pathologic changes in the inner ear, VIII cranial nerve, side being drained-have an emesis basin and/or auditory centers of the brain Tip the head to side that is being irrigated - Causes Place the tip of the irrigating device just inside the external Presbycusis (bilateral progressive hearing loss meatus –tip visible especially at high frequencies in elderly Straighten auditory meatus draw pinna up and down people) Flow of irrigating fluid should be steady, lavage continues High-frequency hearing loss from excessive noise until the cerumen is removed (industrial noise, gunfire, “rock & roll” deafness) Drain excess fluid by tilting the head toward the affected side Hearing Loss Assessment Impacted cerumen must be manuallt extracted by a - History physician or apn with an otoscope and a curette - Physical examination Inspection Taste Examination of ear canal Contributing factors to taste alterations Childhood ear infections → ruptured eardrum → Oral condition Olfactory function jagged white scars on tympanic membrane in elderly ◦ Medications Hearing Handicap Inventory for the Elderly (HHIE-S) - Talk with family members Diseases Common Hearing Problems in Older Persons Surgical interventions Tinnitus Environmental exposure - Objective — pulsatile sounds with turbulent blood Medical conditions flow through the ear Oral status can affect gustatory function o Hypertension Poor dentition → improper chewing → less flavor release o Anemia Improperly fitting dentures → obstruction of palate → o Hyperthyroidism decreased taste perception - Subjective — perception of sound without sound stimulus Oral infections → release of acidic substances → altered o Medications taste + impaired salivary stimulations → decreased ability o Infections for food to dissolve → diminished flavor o Neurological conditions o Disorders related to hearing loss Focused assessment for taste disturbances Head and neck 3 of 6  CARE OF OLDER ADULTS: NURSING CARE OF THE OLDER ADULT IN CHRONIC ILLNESS Mucous membranes Nursing Assessment Interview with focus on past dietary habits - Assess safety and preventive measures Education - Additional assessment Implications of inability to distinguished between salt and Nutrition sugar Patient safety Decreased taste → lack of motivation to prepare + eat → o Date and label all foods o Place natural gas detectors in the home (for gas malnutrition heat) o Place smoke detectors in strategic locations Xerostomia o Establish schedules for personal hygiene and - Cause house cleaning Systemic diseases o Remove kitchen waste every evening Radiation - Learning Objective: Recognize nursing interventions that Medications can be implemented to assist the aging patient with Sjogren’s syndrome sensory changes. - Implications Altered taste Eye Examinations Difficulty swallowing → Risk for aspiration pneumonia - Healthy older adults: Complete eye examination every 1 to Periodontal disease 2 years Speech difficulties → embarrassment → social Visual acuity Retina isolation Intraocular pressure Dry lips + dry mucosa → increased infection + dental - Diabetics caries Complete eye examination annually Halitosis Assessment of Vision Sleeping problems - Observe appearance Clothing cleanliness Nursing Diagnoses Associated with Taste Impairment Self-care - Sensory/perceptual alterations: gustatory Indications of bumps and bruises - Intake less than necessary for caloric requirements Interview Olfactory Dysfunction - Adequacy of vision - Statistics: Males > females - Recent changes in vision - Causes - Visual problems Nasal and sinus disease Red eye Upper respiratory infection Excessive tearing or discharge Head trauma Headache or feeling of eyestrain when reading or Secondary doing close work o Chemotherapy or other medications Foreign body sensation in the eye o Radiation New onset of double vision or rapid deterioration of o Current or past use of cocaine or tobacco visual acuity o Poor dentition New onset of haziness, flashing lights, or moving - Special concerns spots Safety related to smoke and fire Loss of central or peripheral vision Malnourishment Trauma or eye injury - Sense of smell fails to be detected because it is not Date of last exam adequately tested Inspection Use three familiar smells Movement of eyelids Repeat with both nostrils, in different orders Abnormally colored sclera - Nursing diagnoses associated with hyposmia Abnormal or absent papillary response Sensory/perceptual alterations: olfactory Vision Nursing Diagnoses Snellen chart or reading from print - Nursing diagnosis associated with hyposmia Visual field testing Sensory/perceptual alterations: olfactory Extraocular movements - Nursing diagnosis for changes in physical sensations Visual Aids - Helpful aids for visually impaired Sensory/perceptual alterations: tactile Low-vision clinics for suggestions Telescopic lenses 4 of 6  CARE OF OLDER ADULTS: NURSING CARE OF THE OLDER ADULT IN CHRONIC ILLNESS Books in Braille 2) Structural Factors Computer scanners and readers Trauma-subdural hematoma, concussion, contusion, Tinted glasses to reduce glare, large print books and intracranial hemorrhage magazines Tumors- primary and metastatic Seeing eye dogs Normal pressure hydrocephalus Canes Extracranial Disease - Often rejected because of the stigma attached 1) Cardiovascular abnormalities - Very expensive and not covered by Medicare Decrease cardiac output state-myocardial infarction, - Register with Commission for the Blind arrhythmias, congestive heart failure, cardiogenic Books on tape and tape player shock Telephones with large numbers Alterations in peripheral vascular resistance- High-intensity lights increased and decrease states Visual Difficulties May Limit Independence Vascular occlusion-disseminated intravascular Interference with ability to drive coagulopathy, emboli Trouble reading and writing 2) Pulmonary abnormalities Inadequate gas exchange states-pulmonary disease, Identification of Safety Problems at Home alveolar hypoventilation Provide adequate lighting in high-traffic areas Infection-pneumonia Recommend motion sensors to turn on lights when an 3) Systemic infective processes-acute and chronic older person walks into a room Viral Look for areas where lighting is inconsistent; use proper Bacterial- endocarditis, pyelonephritis, cystitis, lampshades to prevent glare mycosis Use contrast when painting so that walls, floors, and other 4) Metabolic disturbances structural elements of the environment can be Electrolytes abnormalities -hypercalcemia, discriminated easily hyponatremia and hypernatrimia, hypokalemia and Avoid reflective floors hyperkalemia, hypochloremia and hyperchloremia, Use “hot” colors, such as red, orange, and yellow for hyperphosphatemia signage Acidosis and alkalosis Urge the use of supplementary lamps near work and Hypoglycemia and hyperglycemia reading areas Acute and chronic renal failure Use red colored tape or paint on the edges of stairs and in Volume depletion-hemorrhage, inadequate fluid entryways to provide warning and signal the need to step intake, diuretics up or down Hepatic failure Avoid complicated rug patterns that may overwhelm the Porphyria eye and obscure steps and ledges 5) Drug intoxifications- therapeutic and substance abuse Teach the importance of walking slowly when entering a Misuse of prescribed medications room Side effects of therapeutic medications Drug-drug interaction ARMD Preventive Measures Improper use of over-the –counter medications - Nurses should encourage Ingestion of heavy metals and industrial poisons Wearing ultraviolet protective lenses in sun 6) Endocrine disturbance Smoking cessation Hypothyroidism and hyperthyroidism Exercising routinely Diabetes mellitus Eating a healthy diet consisting of fruits and Hypopituitarism vegetables Hypoparathyroidism and hyperparathyroidism Taking vitamins in divided doses twice a day to delay 7) Nutritional deficiencies progression = Zinc oxide 80 mgm B Vitamins Vitamin C Physiologic Protein Primary Cerebral Disease 8) Physiologic stress-pain, surgery 1) Nonstructural factors 9) Alterations in temperature regulation-hypothermia and Vascular Insufficiency –transient ischemic attacks, hyperthermia cerebrovascular accidents, thrombosis 10) Unknown physiologic abnormality-sometimes defined as Central nervous system infection- acute and chronic pseudodelirium meningitis, neurosyphillis, brain abscess 5 of 6  CARE OF OLDER ADULTS: NURSING CARE OF THE OLDER ADULT IN CHRONIC ILLNESS Psychologic Sleep- Disturbed, cycle Fragmented Severe emotional stress-postoperative states, relocation, wake cycle reversed hospitalization Depression Impaired verbal communication Anxiety Language barriers (language not of dominant culture) Pain- acute and chronic Cognitive skills (developmental, physiological effects on Fatigue CNS) Short/ long term memory loss, functioning at or Grief below age level Sensory/perceptual deficits-noise, alteration in function Sensory perceptual changes/ loss: hearing vision, post of senses CVA or neurological disease Mania - Receptive aphasia: Client does not have ability to Paranoia receive or interpret verbal/ non-verbal messages Situational disturbances - Expressive aphasia: Client does not have ability to express verbal/ non-verbal messages Environmental How do you communicate effectively with the elderly with Unfamiliar environment creating a lack of meaning in the impaired verbal communication? environment Use proper form of address. Establish respect right away Sensory deprivation or environmental monotony creating by using formal language. a lack of meaning in the Environment Make older patients comfortable. Sensory overload Take a few moments to establish rapport. Immobilization-therapeutic, physical, pharmacologic Try not to rush. Sleep deprivation Avoid interrupting. Lack of temporal spatial reference points Use active listening skills. Demonstrate empathy. Differentiating Dementia and ACS Avoid medical jargon. Clinical Acute confusional Dementia feature state Acute/subacute; Chronic, generally Onset depends on cause; insidious;depend on often occurs at twilight cause Short; diural Long; no diural effects; fluctuations in symptoms progressive, Course symptoms; worse at yet relatively stable night, dark, and on over time awakening Hours to less than 1 Duration Months to years month Fluctuates, generally Awareness Generally clear reduced Fluctuates-reduced or Alertness Generally normal increased Impaired, often Attention Generally normal fluctuates Fluctuates in severity, Orientation May be impaired generally impaired Recent and immediate Recent and remote memory impaired; memory impaired; loss Memory unable to register new of recent memory is information or recall first sign; some loss of recent events common knowledge Disorganized, distorted, Difficulty with Thinking fragmented, slow, or abstraction and word accelerated finding Distorted, illusions, Misperceptions often Perception delusions, or absent hallucinations 6 of 6